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AG 14-015RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIv: PROS / i,, ) 7 2. ORIGINATING STAFF PERSON: ? rt S ! C j'�- EXT: (QC ,G. 3. DATE REQ. BY: I 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 �• CONTRACT AMENDMENT (AG #): f ❑ INTERLOCAL r _ THER a j ±!.� 1 jr �✓1 Gte m YL i l C �i 1M ry YVi 5. PRo.IEcr NAME: Fa IMiI L4 � H o-9 cc '-il'�- � Ski �C -�i1.S � t V-' 6. NAME OF CONTRACTOR:__ %y1/1�D�T FL(JDD��S ADDRESS: TELEPHONE: E -MAIL: FAX: SIGNATURE NAME: K l ✓VI Q Vl. CLt -P 2-- TITLE: Y til VkQ-t/ 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 # 6i2- 2.0ZZ3� EXP, 114Y 8. TERM: COMMENCEMENT DATE: - - 1 COMPLETION DATE: 9. TOTAL COMPENSATION: $ �r j (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. DOCUmW / CONTRACT REVIEW 9"PROJECT MANAGER ❑ SUPERVISOR ❑ DIRECTOR • RISK MANAGEMENT (IF APPLICABLE) • LAw DEPT 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 INITIAL /DATE SIGNED AG# - 1 DATE SENT: INITIAL / DATE APPROVED COUNCIL APPROVAL DATE: DATE REC'D: 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 Ovyy ' y+ V-e-g e} -,S , 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. 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 CITY OF FEDERAL WAY ATTEST Date: l 7 // V Health F Inde cation pfthfj ffim.mu Carol McNeilly, CMC, Ci Clerk 10/2013 HEALTH CARE PROVIDER Sa,vA d e Z Dw a -e-f- (Printed Name and Title) (Organization Name) PAC, , S , She , `? Aj (Address) gs3 - (Phone) Date: ( T STATE OF WASHINGTON ) ss. COUNTY OF i �� - -e dtw- Q �L" q y oO_? On this day personally appeared before me , m s�n/C.�i2� , to me known to be the 19,O Iex of Pe 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. GIVEN my hand and official seal this day of 201tZ NOTARY PUBLIC STATE OF WASHH!G1 -C 7 NANCY C Leal. My Appointment Expires May 17, 2715 K:1Agreements\Parks\2010\Health Fair Indem Notary's signature Notary's printed name Notary Public in and for the Stat6 of Washington. My commission expires fi%aDlS- -2— ' 1 ° CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DDNYYY) 6/10/2013 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(S), 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 SilverStone Group 11516 Miracle Hills Drive Omaha NE 68154 NT CT NAME: Amv Carr PHONE FAX A/C No Ex :: A/c No: AIL homecare@ssqi.com ADD PRODUCER CUSTOMER ID #: BIANC -1 PHPK1027657 INSURER(S) AFFORDING COVERAGE NAIC # EACH OCCURRENCE INSURED INSURER A:Philadelphia Insurance Company 23850 INSURER B: Bianchi Home Care Inc. dba Comfort Keepers 28815 Pacific Hwy. S. Suite 7A INSURERC: INSURER D: $1,000,000 Federal Way WA 98003 INSURER E CLAIMS -MADE rx-1 OCCUR INSURER F: rnvcowr_CC rtCDTICIrtATr- MIIMRPD• I c-7n2 REVISION NUMtltK: 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 LTR TYPE OF INSURANCE ADDLSUBR City of Federal Way POLICY NUMBER POLICY EFF MM/DDNYYY POLICY EXP MM /DDNYYY LIMITS • GENERAL LIABILITY got // fft.A_Ie( grit... PHPK1027657 7/1/2013 7/1/2014 EACH OCCURRENCE $1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTET__ PREMISES Ea occurrence $1,000,000 MED EXP (Any one person) $20,000 CLAIMS -MADE rx-1 OCCUR PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 $ POLICY 7 PRO LOC • AUTOMOBILE LIABILITY PHPK1027657 7/1/2013 7/1/2014 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED AUTOS PROPERTY DAMAGE (P er accident ) $ SCHEDULED AUTOS HIRED AUTOS X X $ NON -OWNED AUTOS UMBRELLA LIAB EACH OCCURRENCE $ HOCCUR AGGREGATE $ EXCESS LIAR CLAIMS -MADE DEDUCTIBLE $ $ RETENTION $ WORKERS COMPENSATION \WC STATU- O R AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ OFFICER/MEMBER EXCLUDED? ❑ (Mandatory In NH) NIA A E.L. DISEASE - POLICY LIMIT $ If yes describe under DESCRIPTION OF OPERATIONS below A Professional Liability Property Crime PHPK1027657 7/1/2013 7/1/2014 Limit $1M /$2M Limit Per Schedule Limit $50,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Certificate holder is listed as additional insured with respect to the Commercial General Liability policy. /�fCtaTIC1/�ATL- IJAi non r`AMr`CI I ATlf1M U 7V55 -LUUV AGUKU L UKrUKA l Ivry. An rlgms reaarvau. ACORD 26 (2009/09) 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 33325 8th Ave S. AUTHORIZED REPRESENTATIVE Federal Way WA 98003 got // fft.A_Ie( grit... U 7V55 -LUUV AGUKU L UKrUKA l Ivry. An rlgms reaarvau. ACORD 26 (2009/09) The ACORD name and logo are registered marks of ACORD