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AG 13-037RETURN TO: �r' � EXT: �� U Z CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIV: ORIGINATING STAFF PERSON: F+� ' �.r I\I �� � ri EXT: 2- 3. DATE REQ. BY: 4. TYPE OF DOCUMENT (CHECK ONE�: ❑ CONTRACTOR SELECT[ON DOCUMENT (E.G., RFB, RFP, RFQ� ❑ PUBLIC WORKS CONTRACT ❑ SMALL OR L[MITED PUBLIC WORKS CONTRACT ❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT ❑ GOODS AND SERVICEAGREEMENT ❑ HUMAN SERVICES / CDBG ❑ REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS) ❑ ORDINANCE ❑ RESOLUTION ❑ CONTRAC\T\AMENDMEcNT(AG#y): ❑ INTERLOCAL '�OTHER tiPr ���. TL"r 1✓l�' �+ �� o�n �orm S. PROJECT G. NAME OF CONTRACTOR: � f_ �� I 1-S�� ADDRESS: � 14 � � � TELEPHONE: Z�3� la - a�� E-MA[[.: F�� SIGNATURE NAME: TITLE: 7. EXHIB[TS AND ATTACHMENTS: ❑ SCOPE, WORK OR SERVICES ❑ COMPENSAT[ON ❑ INSURANCE REQUIREMENTS/CERTIFICATE ❑ ALL OTHER REFERENCED EXHIB[TS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS CFW LICENSE # BL, EXP. 12/31/ UBI # , EXP. / /_ 8. TERM: COMMENCEMENT DATE: �I �G I I�i COMPLETION DATE: `I ��l �i -� I. TOTAL COMPENSATION: $ � (INCLUDE EXPENSES AND SALES TAX, IF ANY� ([F CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOL[DAY RATES� REIMBURSABLE EXPENSE: ❑ YES ❑ NO IF YES, MAXIMUM DOLLAR AMOUNT: $ IS SALES TAX OWED: ❑ YES ❑ NO [F YES, ❑ PURCHASING: PLEASE CHARGE TO: lO. DOCUMENT / CONTRACT REVIEW ❑ PROJECT MANAGER ❑ SUPERVISOR ❑ DIRECTOR ❑ RISK MANAGEMENT (IF APPLICABLE� ❑ LAw DEpr 11. COUNCILAPPROVAL ([F APPLICABLE) IN[TIAL / DATE REVIEWED COMMITTEE APPROVAL DATE: 12. CONTRACT SIGNATURE ROUTINC ❑ SENT TO VENDOR/CONTRACTOR DATE SENT: ❑ ATTACH: S[GNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS LAW DEPT S[GNATORY �M�AYOR OR D[RECTOR� � CITY CLERK �. ASS[GNEDAG # I� SIGNED COPY RETURNED � ❑ RETURN ONE ORIGINAL COMMENTS: � INITIA / DATE S[GNED Z•��'� AG# " DATE SENT: Z ' I ' PAID BY: ❑ CONTRACTOR ❑ C1TY INITIAL / DATE APPROVED COUNCIL APPROVAL DATE: DATE REC' D: 11/9 RETURN TO: EXT: CITY OF � DER.AL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT./DIV: �2C S 2. ORIGINATING STAFF PERSON: �1 YYl JI/��Ab1/ � EXT: �9�3Z 3. DATE REQ. BY: I�{ I 4. TYPE OF DOCUMENT (CHECK ONE): �d ��� � ❑ CONTRACTOR SELECTION DOCUMENf (E.G., RFB, RF�FQ) n0 ���'�-- ❑ PUBLIC WORKS CONTRACT � SMALL OR LIMITED PUBLIC WORKS CONTRACT � I�� � 3 O PROFESSIONAL SERVICE AGREEMENT O MAINTENANCE AGREEMENT ❑ GOODS AND SERVICE AGRGEMENT O HUMAN SERVICES / CDBG � REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT' (EC. eorm x�uTen no�rs) ❑ ORDINANCE ❑ RESOLUTION ❑ CONTRACT NDNIENT (AG#? : O INTERLOCAL � o� P a.l-F� Fc�.t ✓ ( � d�a�la �71' cz� ��. �7 � 5. PROJEGT NAME: �d.i/Yl l I v1 t-� �-�+� �����r�i"t � ��-� 6. NANiE OF CONTRACTOR: _� _ � ADDRESS: `.% — -y--- . s•_. . � TELEPHONE E-MAII,: FAX: SIGNATtTRE NAME: T�E 7. EXFIIBTTS AND ATTACHMENTS: O SCOPE, WORK OR SERVICES ❑ COMPENSATION � aVSURANCE REQU�NI'S/CERTIItICATE O ALL p'li�R REFERENCED EXHIBITS ❑ PROOF OF AUTHORiTY TO SIGN ❑ REQ(JIItED LICENSES ❑ PRIOR CONTRACT/AMENDI�IV'fS s. �: co�xcE�rrr na�: 1 �2.� � �3 Lo a.W� COMPLETTON DATE: �!��� 3 Z.,o,�,� 9. TOTAL COMPENSATION $ � (n�rcwne �ExsaS Axu s�s r�x, � �rnr) (IF CALCULATED ON HOURLY LABOR HARGE - ATfACH SCHEDULES OF EMPLOYEES 77fLES AND HOLIDAY RATBS) REINIDURSABLE E7�ENSE: O�s ❑ xo ��s, M�[� nor.[.nR nMO[�rm $ IS SAI.ES TAX OWED O YES ❑ NO 1F YES, � PAID BY: 0 CON[RACDOR O CII'Y O PURCHASING: PLEASE CHARGE TO: 10. NTlCONTRACT REVIEW /DATEREVIEWED `�`,� j� INITIAL�DATEAl'PROVED ROJECT MA,NAGER '�iGi!\ 1 t ��� t ...�r DIRECTOR �K-3�-�{� ��s�a� _ — LAW � i�6 af113 � 1 Z$ �ot�'S ' A�4 �w� ��'S w �' ' r 11. COiJNCII..APPROVAL(�nPPt,ccnsr�) CO EAPPROV DA ' COUNCILAPPROVAL ATE: 12. CONTRACT SIGNATURE ROUTIIVG • ❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D: ❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBTTS ❑ LAW DEPARTMENT � SIGNATORY (cM oR n�croR) p� crrY cr.�c �p� ASSIGNED AG# 0� SIGNED COPY RETURNED T D E S GNED �,� �'3D' 13 AG# �I�' DATE SENT: 1- � -1 � CObIl4tENTS: ��W�,l� ��� r'�' �P,e-1'1 V� 70�' ��GC.t'1'b(/ i►�l �ro INDEMNIFICATION AND INSURANCE AGREEMENT This Indemnification and Insurance Agreement ("Agreement") is dated effective the later date indicated below with the signature. The parties ("Parties") to this Agreement are the City of Federal�� Way, a Washington municipal corporation ("City") and �n t n� I�r-i�� �G�uPu�'F'�'� a ("Health Care Provider"). A. The Health Care Provider wishes to contribute services for the Federal Way Family Health & Safety Fair on January 26, 2013; and B. The City wishes to cooperate by allowing the use of the Federal Way Community Center, 876 S. 336th Street, Federal Way, Washington. Vendor space is $50. NOW, THEREFORE, the Parties agree as follows: 1. Indemnification. In consideration of the City authorizing its use of the Federal Way Community Center, the Health Provider agrees to indemnify and hold the City, its elected officials, ofiicers, employees, agents, volunteers, sponsors, contributors and donors harmless from any and all claims, demands, losses, actions and liabilities (including costs and all attorney fees) to or by any and all persons or entities, including, without limitation, their respective agents, licensees, or representatives, arising from, resulting from, or connected with this Agreement or the use of the Federal Way Community Center or relating to the Family Health & Safety Fair to the extent caused by the acts, errors or omissions of the Health Care Provider, its partners, shareholders, agents, employees, invitees or by the breach of this Agreement. 2. Insurance. The Health Care Provider agrees to submit a Certificate of Insurance evidencing Commercial General Liability in the amount of no less than $1,000,000 naming the City of Federal Way as additional insured and Professional Liability insurance in the amount of no less ihan $1,000,000. The Certificate should be presented with the executed Agreement no later than ;Friday, January 11, 2013. Failure to submit proof of such insurance and execute this Agreement shall prohibit the Health Care Provider from participating in the Federal Way Community Center Health •Fair on January 11, 2013. 3. City Contact. Submit the certificate of insurance and the executed Agreement no later than Friday, January 1 l, 2013, to: Kimberly Shelton, Fitness/Athletic Coordinator City of Federal Way 8?6 S. 333`d St. Federal Way, WA 98003 CITY OF FEDERAL WAY Skip Priest, Mayor Date: 2/ � � I � 3 -1- ATTEST arol McNeilly, CMC City Cle HEALTH CARE PROVIDER ,' Signature) ,�1��'C� .6�Gt�'�?r r � �. J'�1,��1 (Printed Name and Title) �li�l � � Y�- i` � ' Y'''� �Z�JL (Organization N e) r � � 3l� S"� �� �� �. �,� l�� (Address) ��> ������w (Phone) Date: r �� STATE OF WASHINGTON ) ) ss. COUNTY OF _��� P►c�Cxcc� ��� On this day personally appeared before me , to me known to be the ('�, , ��� of '" � �- that executed the foregoing instrument, and acknowledged th said instrument to be the free and voluntary act and deed of said corporation, for the uses and purposes therein mentioned, and on oath stated that he/she was authorized to execute said instrument and that the seal affixed, if any, is the corporate seal of said corporation. GIVEN my hand and official seal this �f�day of �grt � , 20� `���11111/���� I ���•��N.a Po9�,� .��: �slop F. �i �� �� .f••�i ' . � ppi +% : � � :o � :y ��'� ��;� :: = � ' �"°u� � ,: . . • %�� ;��.�4 �; �``� ''� ��FWA••.•``,```�� �llfllll� K:Wgreements�Parks\2010U-Iealth Fair Indem JQ � Notary's signature ,/ � � ( Notary's printed name . Notary Public in and for the State of Washington. • My commission expires ����5 �J�r7t�' ,r -2- Jan G413 04:25p • � CERTIFICATE OF INSURANCE p.1 n... �..., This certifies [hat � S�ATE FARM FIRE AND CASUALTY COMPANY, Bloornington, Illinois ❑ STATE �ARM GENERAL INSURANCE COMPANY, Bloomington, lllinois IOfYlANCfb ❑ STATE �ARM FIRE AND CASUALTY COMPANY, Aurora, OMario ❑ STATE FARM FLORIDA INSURANCE COMPANY, Winter Haven, Florida ❑ STATE FARM LLOYDS, Qailas, Texas insures the iollowing policyholder far the coverages indicated below: POIiCyhOEde[ �ANCING TURT�E ACUPUNCTURE LLC Address of policyholder 33650 6TH AVE S STE 100, FEDERAL td?�.Y, wA 96003 Location of operatiens FEDEP.AL WA� COMMUNITX CENTER pescr�ption of operations rcUPUNCTVRE The policies listed below have been sssued to the policyholder for the policy periods shown. The insurance described in these policies is subject to ail the terms, exclusions, and condi6ons of thase policies. The limits of liahiliiy shown may have been �educed by any paid claims. POLICY PERIQD LIMITS OF LIABILITY PQLICY NUMBER TYPE OF INSURANCE Effective Date � E.�iration Date (at beginning of p�licy period) Comprehensive 08/21!11 � 08/21l2013 BODILY INJURYAND �a-sF-L8o0-5 F �usiness Liability � PROPERTY DAMAGE ----------------------------- ---------------------------- ------------------�----------- This insurance includes: ❑ Products - Cornpleted Operations ISI Cont�actual Liability Each Occurrence � l000c•o� � Personal Injury ❑ Advertising knjury GeneralAggregate $ 2000000 ❑ ' � Products-Cumpleted $20�0000 � I� OperaGons P�qgregate _ AUTOMOTIVE PQLICY NUMBER EKCESS LIABILITY ❑ Umbrella . � Other 1Norkers' Cornpensabon and Emptoyers Liability TYPE OF INSURANCE PCILICY PERIOD Effective Date '� ExP�tion Dahe oa�2i�ii oa/21,'12 POLICY PERIOD Effective Date ; Expiration Daie OE/21/11 OB/21/12 POLICY PERIOD Effective Date ; Expiration Dabe BODILY INJURY AND PROPERTY DAMAG� (Combined Singfe Limit) Each Occurrence S i000000 Aggregate $ 1000000 Part I- Workers CompeRSation - Statulory Part II - Employers liability Each Accident � l000000 Disease - Each Employee $ 100000� Disease - Poticy Limit $ �000000 LIMITS OF LIABILITY (at beginning oF policy pereod) THE CERTIFICATE OF fNSURANCE IS NOTA C�NTRACT OF INSURANCE AND NE[THER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COYERAGE APPROVED BY ANY POLICY DESCFtIBEO HEREIN. Hame and Address of Certficaie Holder ADDITIONAL TNSURED CETY OF F£DERAL WAY 876 S 333x` FEDEAL WAY, kA 98003 A.DBL ?NSURED — SE�TION II NATUi2AL 33E�LTI-E CENTER LLC 33654 6TH aGE S STE 100 FEDERA� I�AY '�TA 98003 ADDL INSURE� — SECTICN II SUN LI?E ASSURA[ZCE COMPANY OF CANADA (USA) NAI, NORRIS, BEGGS & SIMPSON 600 UNIVERSII'Y ST STE 1G2E SEAT^LE wA 98101-41G7 558-994 a.6 Prinled In U S.A. Rev_ OS-09-20U6 If any of the described policies are canceled befa'e Itieir expiration c�te, State Farm wial try lo mail a wriflen noticae to the certificafe holdec 4 5 days b�fore cancellation. If however, we fail to mail such notice, no obligatio� or liablity will be imposed on SCate Farrn ' agents� preserrtatives. �r� _ Signa re of Auth ' Representative �ff'c Rep 09/07l2012 Title Date Julie Lehn:k 1 Agent Name Telephone Number 253-927-9295 Agent's Code Stamp AgentCode 47-25C5 AFO Code F502