Loading...
AG 14-008RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIv: PRCS / 2. ORIGINATING STAFF PERSON: k. f yV1 PiuG4 56 t+` A EXT: - 3. DATE REQ. BY: 4. TYPE OF DOCUMENT (CHECK ONE): ❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ) ❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT ❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT • GOODS AND SERVICE AGREEMENT ❑ HUMAN SERVICES/ CDBG • REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS) ❑ ORDINANCE ❑ RESOLUTION ❑ C�NTRACTAMENDMENT (AG #): ^ 11 INTERLOCAL OTHER L F It .fit GA l ✓ I Ill d 1M d'LCa , 6hBYN't 5. PROJECT l 6. NAME OF ADDRESS: E -MAIL: SIGNATURE NAME' r L..�'- FAX: TITLE: f 1° 7. EXHIBITS AND ATTACHMENTS: ❑ SCOPE, WORK OR SERVICES ❑ COMPENSATION ❑ INSURANCE REQUIREMENTS /CERTIFICATE ❑ ALL OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT /AMENDMENTS CFW LICENSE # BL, EXP. LL12 /31/ UBI # 11 , EXP. l 8. TERM: COMMENCEMENT DATE: i _ t �' �T COMPLETION DATE: ' a . I4 9. TOTAL COMPENSATION: $ (INCLUDE EXPENSES AND SALES TAX, IF ANY) (IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES) REIMBURSABLE EXPENSE: ❑ YES ❑ NO IF YES, MAXIMUM DOLLAR AMOUNT, IS SALES TAX OWED: ❑ YES ❑ NO IF YES, $ PAID BY: ❑ CONTRACTOR ❑ CITY ❑ PURCHASING: PLEASE CHARGE TO: 10. DOCUm / CONTRACT REVIEW 4 PROJECT MANAGER • SUPERVISOR • DIRECTOR ❑ RISK MANAGEMENT (IF APPLICABLE) ❑ LAW DEPT INITIAL /DATE REVIEWED INITIAL /DATE APPROVED 11. COUNCIL APPROVAL (IF APPLICABLE) COMMITTEE APPROVAL DATE: 12. CONTRACT SIGNATURE ROUTING ❑ SENT TO VENDOR/CONTRACTOR DATE SENT. ❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS • LAW DEPT • SIGNATORY (MAYOR OR DIRECTOR) • CITY CLERK • ASSIGNED AG # • SIGNED COPY RETURNED ❑ RETURN ONE ORIGINAL COMMENTS: f_ Le &I kz watvej INITIAL/ DATE SIGNED J AG DATE SENT: D' COUNCIL APPROVAL DATE: DATE REC'D: 11/9 FEDERAL WAY FAMILY HEALTH & SAFETY FAIR 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 Virginia Mason Medical Center, a Washington nonprofit corporation located at 1100 Ninth Avenue, Seattle, WA 98101 ("Health Care Provider "). A. The Health Care Provider wishes to contribute services for the Federal Way Family Health & Safety Fair on January 18, 2014; and B. The City wishes to cooperate by allowing the use of the Federal Way Community Center, 876 S. 3361 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, officers, 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 and Professional Liability insurance in the amount of no less than $1,000,000. The Certificate should be presented with the executed Agreement no later than January 3, 2014. 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 18, 2014. 3. Providers who are only handing out informational brochures and not providing any screening, diagnosis, or medical services do not need to provide proof of insurance as required in section 2 above. 4. City Contact. Submit the certificate of insurance, if required, and the executed Agreement no later than January 3, 2014 to: Kimberly Shelton, Fitncss/Athletic Coordinator City of Federal Way 876 S. 333rd St. Federal Way, WA 98003 Apeemenis\City of Federal Wayllndemnif"ion and Insurance AgreemenAFinal 17dec 13 CITY OF FEDERAL WAY yor J'i �rrtt l Date:— %) a I / '-I VIRGINIA MASON MEDICAL CENTER (S gnature) Darlene S. Corkrum Senior Vice President & Chief Marketing Officer 1100 Ninth Avenue PO Box 900 (MS: GB -ADM) Seattle, WA 98111 206 - 223 -6912 Date: h-# STATE OF WASHINGTON ) COUNTY OF ATTEST Pto) a I Carol McNeilly, "CitClerk On this day personall ared before meARl.(.�� S COQaVM , to me known to be the 1�1 I�r+�f'� of .ft&&IAph/Mg&(At 40yTVk -. that executed the foregoing instrument, and ac o e�the 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, hand and official seal this J611'Lday of )6;Mg. , 2013. Notary's signature 9X, Notary's printed name KE+/ g. �AdVton�DA�i�✓� Notary Public in and for the State of Washington. My commission expires Health Fair Indemnification 10/2013 ERTI FICATE OF INSURANCE P.O. Box 900, G1 -PS 1100 Ninth Avenue Seattle, WA 98111 P: (206) 583 -6007 F: (206) 515 -5899 Effective May 31, 2013 Virginia Mason Health System's Self- Insured Professional Liability Program covers the employees of Virginia Mason Health System while acting within the scope and during the course of their employment with Virginia Mason Health System, for all acts that are normally covered by customary general and professional liability insurance policies. This program is continuous and does not expire; however, termination of employment terminates coverage. Additional Insureds include students, employees and authorized volunteers when working for Virginia Mason Health System within the scope of their duties. This includes employed interns, externs, residents, certified registered nurse anesthetists, physician's assistants, dentists, osteopathic physicians and surgeons, physicians, podiatrists and surgeons, when working within the scope of their duties for Virginia Mason Health System. Csim W and RvNeelonal Liabift.. Products - Comp /Op Agg $ NIL Commercial General Liability, Medical Professional Personal & Adv Injury $ Included Liability Each Occurrence $ 1,000,000 Contractual Liability Fire Damage (Any one fire) $ Included Because this is self- insured by Virginia Mason Health Medical Expense (Any one $ N/A System there is no " policv number" person) Coverage provided by Virginia Mason Health System's Self- Insured Program is continuous and applicable to all general and professional liability claims occurring while the Virginia Mason Health System employs the provider irrespective of when a claim is made. Name of Event: Federal Way Family Health and Safety Fair Date of Event: January 18, 2014 Physical Location: 876 S. 333rd St., Federal Way, WA 98003 Certificate Iesued with wiprel s authorization of Mrorde Mason Health System, Manager, Rlsk Flnandng & Claims. City of Federal Way 876 S. 333rd St. Federal Way, WA 98003 I Daft Issued: December 16, 2013 1 LM/sbw This document Is conferred as Information only, does not alter coverage afforded by the Self-Insuranoe Plan In arty way, and guarantees the holder no rights beyond those extended In the policy.