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AG 14-014RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/Div: 2. ORIGINATING STAFF PERSON: Ki al he r( JV 1 e i K-n EXT: 3. DATE REQ. BY: I-7 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 #): ❑ INTE(RLOCAL �❑ THER t- r- �t_i -�'1� �{ 1 Imo• ✓1 �Q iYI I11 �I C�"i1 nv1 T'v� YY1 5. PROJECT NAME: F-a yyyx lf4 A �'�'� `` S ±Lj Fa t v- am 1 6. NAME OF CONTRACTOR: e k W Li t- S ADDRESS: TELEPHONE: E -MAIL: FAX: SIGNATURE NAME: Gl r l M l I IPIA Je V TITLE: X• ct t rLll),- 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. 12/31/_ UBI # (.o3 2 -Z�-7Ie 3 ii, EXP. 2_/31 /_�V 8. TERM: COMMENCEMENT DATE: t �7 - H COMPLETION DATE: I l 9. TOTAL COMPENSATION: $ C2Q • (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: $ 1S SALES TAX OWED: ❑ YES ❑ NO IF YES, $ PAID BY. ❑ CONTRACTOR ❑ CITY ❑ PURCHASING: PLEASE CHARGE TO: 10. DOCUMpT / CONTRACT REVIEW lkTROJECT MANAGER ❑ SUPERVISOR • DIRECTOR • RISK MANAGEMENT (IF APPLICABLE) • LAW DEPT 11. COUNCIL APPROVAL (IF APPLICABLE) g /jam m COMMITTEE APPROVAL DATE: 12. CONTRACT SIGNATURE ROUTING • SENTTO 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 0 INITIAL / DATE SIGNED AG# " 1 DATE. SENT INITIAL / DATE APPROVED COUNCIL APPROVAL DATE: DATE REC'D: 1/9 .i Ir 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 Guided Pathways — Support for Youth and Families, a Family Support Organization ( "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. 336' 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 Indemnification 10/2013 CITY OF FEDERAL WAY �i._L�. P , Susan Millender, Executive Director (Printed Name and Title) ATTEST C�M,o ff)CD III Carol McNeilly, CMC, Ci Clerk Guided Pathways — Support for Youth and Families (Organization Name) 6625 S 1901' St, Ste B -108, Kent, WA 98032 (Address) 253- 236 -8264 (Phone) Date:O ST E OF WASHINGTON ) ) ss. COUNTY OF KING ) On this day personally appeared before me Susan Millender' to me known to be the Executive Director of Guided Pathways — Support for Youth and Families 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. and official seal this i V %^ day of 5XM WWIA 9201J. Notary's signature . Notary's printed name W Notary Public in and for the State �of�Was Washington. My commission expires �0 -2- 10/2013 GUIDE -1 OP ID: SR CERTIFICATE OF LIABILITY INSURANCE DAT12/26/13 ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone: 206 - 623 -7035 CONTACT NAME: Sprague Israel Giles Fax: 206 - 682 -4993 1501 Fourth Avenue, Suite 730 Seattle, WA 98101 -3225 HONE N t AX No ADORLEss: CA License #0192858 Nick King INSURERS AFFORDING COVERAGE NAIC # INSURER A : Philadelphia Indemnity Ins. 18058 $ 100,00 INSURED Guided Pathways 6625190th Street Suite B108 Kent, WA 98032 INSURER B: X INSURER C : PHPK1101667 11116/13 11/16114 MED EXP (Any one person) INSURER D INSURER E: INSURER F : CTICIPATC LI"RACCO. RFVINFLIN NIIMISL'K: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LT., TYPE OF INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE POLICY NUMBER MMIDDrNYY MMIDD/YYYY LIMITS GENERAL LIABILITY AUTHORIZED REPRESENTATIVE �J EACH OCCURRENCE $ 1,000,00 PREMISES Ewa ooc $ 100,00 A X COMMERCIAL GENERAL LIABILITY X PHPK1101667 11116/13 11/16114 MED EXP (Any one person) $ 5,0 CLAIMS -MADE ❑X OCCUR PERSONAL &ADV INJURY $ 1,000,00 GENERALAGGREGATE $ 3,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PEG- LOC JECT PRODUCTS - COMP /OP AGG $ 3,000,E STOP GAP $ INCLUDE D AUTOMOBILE LIABILITY Ea accident $ 1,000,00 BODILY INJURY (Per person) $ A — ANY AUTO PHPK1101667 11/19113 11116/14 BODILY INJURY (Per accident) $ ALLOWNED SCHEDULED AUTOS AUTOS X HIRED AUTOS X AUTOSSWNED PRO15ERTY DAMAGE Per accident $ $ UMBRELLA LIAR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB HOCCUR CLAIMS -MADE DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER/EXECUTIVE Y I�N OFFICERIMEMBER EXCLUDED? (Mandatory in NH) WCSLIIMT OTR $ N / A E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ If Yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder is additional insured with respects liability arising out of operations by or on bgUalf of the named insured for General Liability, subject to a written contract= being in force. u�, n f`AaJf`=I I eTInN Uluatf -AuivA%IVKIJVVRI- VIViIIv . 0l11 1V1 Ivacl• - ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Federal Way Attn: Kimberly Shelton 876 South 333rd Street Federal Way, WA 98003��L��� AUTHORIZED REPRESENTATIVE �J Uluatf -AuivA%IVKIJVVRI- VIViIIv . 0l11 1V1 Ivacl• - ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD