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AG 14-012RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIv: PROS / 2. ORIGINATING STAFF PERSON: K�? alt % -7 J� t' EXT: II�C 3. DATE REQ. BY: L 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 NTRACT AMENDMENT (AG #): ❑ INTERLOCAL �❑ THER � � t�cle iYl Yl t {i C�� uvt �W i'1/1 5. PROJECT NAME: _ F7a t/ x 1q H- -�-1- 54, ('C- T I t V- 6. NAME OF CONTRACTOR: �& 1 ST I a e' ADDRESS: TELEPHONE: E -MAIL: FAX: SIGNATURE NAME: 1_S l� !.� n i.) TITLE: 6 W ✓L0— 7. EXHIBITS AND ATTACHMENTS: ❑ SCOPE, WORK OR SERVICES ❑ COMPENSATION ❑ INSURANCE REQUIREMENTS /CERTIFICATE ❑ ALL OTHER REFERENCED EXHIBFFS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT /AMENDMENTS CFW LICENSE # BL, EXP.,,1ff2 /31/_ UBI # , EXP. S. TERM: COMMENCEMENT DATE: i "f COMPLETION DATE: I - l F " I q 9. TOTAL COMPENSATION: $ a . � (INCLUDE EXPENSES AND SALES TAX, IF ANY) (IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TFFLES 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: !J� m 10. DOCUMw / CONTRACT REVIEW k'PROJECT MANAGER ❑ SUPERVISOR ❑ DIRECTOR ❑ RISK MANAGEMENT (IF APPLICABLE) ❑ LAw DEPT 11. COUNCIL APPROVAL (IF APPLICABLE) I Jill MR'iliIIf[�C COMMITTEE APPROVAL DATE: 12. CONTRACT SIGNATURE ROUTING ❑ SENT TO VENDOR/CONTRACTOR DATE SENT: ❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBFFS • LAW DEPT • SIGNATORY (MAYOR OR DIRECTOR) • CITY CLERK • ASSIGNED AG # • SIGNED COPY RETURNED ❑ RETURN ONE ORIGINAL INFFIAL / LLOg SIC.41ED f AG# DATE SENT: INFFIAL / DATE APPROVED COUNCIL APPROVAL DATE: DATE REC'D: r''' -S56--10qSj --k, ttnw�-Ly i FEDERAL WAY FAMILY HEALTH & SAFETY FAIR INDEMNIFICATION AND INSURANCE AGREEMENT r 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 ���6, a ( "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. 3300 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 naming the City of Federal Way as additional insured 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, Fitness /Athletic Coordinator City of Federal Way 876 S. 333rd St. Federal Way, WA 98003 Health Fair I emnification 10/2013 CITY OF FEDERAL WAY t, Jdayor �.J1 , T �+I Date: 7 HEALTH C PROVIDER :4�4� 4:��no, (Printed Name and Title) ATTEST rw,u wcf� I . - aw Carol McNeilly, CMC, Ci Clerk "M (Organization lk (Address) (Phone) Date: STATE O WASHINGTON ) ) ss. COUNTY OF KI N On this day personally appeared before me 14K ISg(N A 6 N kW , to me known to be the 514 Ntif�- of 14 00 2 tie I Vy ST? S "TZ t Z( 1j A that executed the foregoing instrument, and acknowledged 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. r Lv" 5'9""M M"M MM- AM, official seal this 1 ')74day of &kNVfiff-% , 201 . Notary's signature k Notary's printed name 1 Kq L u Notary Public in and for the State of Washin on. My commission expires d" - ;-,-z , 26 Health Fair Indemnification 10/2013 -2- ALLI ED PROFESSIONALS INSURANCE COMPANY, A Risk Retention Group, Inc. p�mericaure Declarations to Claims Made Professional Liability Policy Named Insured/Certificate Holder: Member Policy No: Master Policy.- Master Policy Held By: Professional Services: Claims Reporting Basis: Endorsement(s): Premises Liability: Exclusions: Limitations: Territory: Professional Liability Policy Limits: Covered Proceedings Limits: Total Annual Cost Basis: Premium Based On: Lapse Dates: Retroactive Date: Policy Period: Please direct all inquiries to your broker. Krishna Deborah Shaw, L.Ac. APIA- 521440 APIC-AAC-1001 -Elite; Issued in CA American Acupuncture Council Acupuncture and Oriental Medicine Claims Made X2002 (Acupuncture) Yes Deductible- None As stated in Section V of Endorsement to Policy Disposable Needles Only United States • Subject to proper licensing in states where services are rendered (See Exclusion A7.) $1,000,000 Each Claim/ $3,000,000 Aggregate $30,000/$30,000 $ 936.00 (Premium - $ 569.50; Policy Fee - $100.50; Membership Fee - $ 200.00; Install Chrg - $ 66.00) Annual Reporting Period Payment Plan: Quarterly From To: 10/10/2012 From 10/10/2013 To: 10/10/2014 Phone: (All dates are at 12:01 am at address of Named Insured. Unless renewed, coverage ends on the Expiration Date.) General: This Declarations Page identifies the person(s) named herein as a named insured under the terms and conditions of a Policy issued to the members of the American Acupuncture Council. The terms and conditions of the Policy apply to all members who hold a Certificate of Insurance. The terms and conditions of this Certificate apply only to the person(s) named herein and the insurer. The Retroactive Date listed above applies only to those attributes of coverage in place continuously since the inception of the Named Insureds • Policy. When changes to coverage are requested, including but not limited to changes in Limits, switching from Preferred to Elite, adding Professional Services, etc., such changes are effective retroactively only to the date the change was approved by the Company. Coverage: Coverage is afforded to person(s) named herein as Named hvsureds according to the terms and conditions of the Policy to which this Certificate refers. No other rights or conditions, except as specifically stated herein, are granted or inferred. When your Claims Reporting Basis is •Cfaims Made-, the Policy affords defense and damage coverage only for claims made against the Named Insured 1) arising from the performance of Professional Services rendered subsequent to the Retroactive Date, and 2) made against the Named Insured and reported to the Company during the Policy Period. Please review the policy carefully and discuss any questions regarding coverage with the insurance broker at (800) 838 -0383. Extended Coverage: If your Claims Reporting Basis is -Claims Made- and the Policy is terminated either by you or the Company, you may apply for Extended Coverage so that you can submit claims after your Policy Period ends for incidents that occurred during your Policy Period. An application for Extended Coverage must be received within thirty (30) days of termination of your Policy, unless otherwise modified by any applicable State Mandatory Endorsement attached hereto. Notice: Report in writing within 48 hours any & all claims against you and any & all incidents that you believe may result in a claim against you, even if groundless, to American Acupuncture Council, 1100 W. Town and Country Road, Suite 1400, Orange, CA 92868. Notice: This Policy is issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your State. State insurance insolvency guaranty funds are not available for your task retention group. Countersigned by. Pdnte& S!11013 10f1 A4001 '� �°�S�n�i