Loading...
AG 15-020 RVURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIV: PRCS/ 2. ORIGINATING STAFF PERSON: She D Y\ EXT: 1 3 2 3. DATE REQ.BY: r I S 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 AM NDMENT AG#): ❑ INTERLOC ( , X OTHER 'I e A t c a'4"7 r3--Y\ F)rat— .re,1 AA, c 5. PROJECT NAME: ((U •-p �J1 �� E/�(.,r 6. NAME OF C9NTRACTOR: 1 C.ht I D Cri ADDRESS: l S 3(2. `• _ ` C L TELEPHONE: a,s-3 (cc/0? E-MAIL: FAX: SIGNATURE NAME: S.jLe-p ka-r\ Rest I,A TITLE: C)(AJ /\E 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# ,EXP. 1 / / /8. TERM: COMMENCEMENT DATE: `/I / l S COMPLETION DATE: I L �I I t S- 9. TOTAL COMPENSATION:$ 0 (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. DOCUMENT/CONTRACT REVIEW INITIAL/DATE VIEWED INITIAL/DATE APPROVED PROJECT MANAGER Z V243 i. l -f ❑ SUPERVISOR ❑ DIRECTOR ❑ RISK MANAGEMENT (IF APPLICABLE) CLAW DEPT 47 1/15//r * 11. COUNCIL APPROVAL(IF APPLICABLE) COMMITTEE APPROVAL DATE: COUNCIL APPROVAL DATE: 12. CONTRACT SIGNATURE ROUTING ❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D: ❑ ATTACH: SIGNATURE AUTHORITY,INSURANCE CERTIFICATE,LICENSES,EXHIBITS INITIAL/DATE SIGNED ❑ LAW DEPT / ` SIGNATORY(MAYOR OR DIRECTOR) �� /MA 17 S !r CITY CLERK �/;/ �- X ASSIGNED AG# AG. - I,_ 9(SIGNED COPY RETURNED DATE SENT: I _ ❑RETURN ONE ORIGINAL COMMENTS: * i t, e c-t n l w'e, iol P c i f r J o U e 4 1 1 Co v /lads 4IA ro ti Ld tn/ t ep a4-i vv/0-4- era' -to a&Wei rv. vex, JOr Co l• .tictc or-kJ ' ; Sth1 vq • a - , I L L s /' fi' Wa4 vie 6ftx' 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 Ci ty of Federal Way, a Washington municipal corporation("City")and I ('4' I ro patch c ((4.. ;a ("Health Care Provider"). A. The Health Care Provider wishes to contribute services for the Federal Way Family Health&Safety Fair on January 17, 2015; 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,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 2, 2015. Failure to submit proof of such insurance and execute this Agreement shall prohibit the Health Care Provider from participating in the Family Health& Safety Fair on January 17,2015. 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 2, 2015 to: Kimberly Shelton, Fitness/Athletic Coordinator City of Federal Way 876 S. 333rd St. Federal Way, WA 98003 Health Fair Indemnification 10/2013 . r CITY OF FEDERAL WAY ATTEST Jim Ferrell °:yo ' _ , CMC, City I Date: HEALTH CARE PROVIDER/VENDOR !P (Signature) (Printed Name and Title) (Organization Name) j 2/7 5 . f - G (Address) s3 - (Phone) Date: /A-- STATE OF WASHINGTON ) ) 5S. COUNTY OF [r/—`1' An this/ day personally appear be f re me \y?\-Q V'\Q '1 ( ) ball, to me known to be the QS\�Q,�� of �`I t 1:2 e,,Q r,ti i •c- 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 t day of \ r_ • • , ■ Notary's signature 1-�•' ,fir ' • ' ��N Notary's printed name :ta.1e , Notary Public in and for the State of Washington. My commission expires a Notary Public State of Washington YEKATERINA PECHENYUK My Appointment Expires Jul 10,2015 Health Fair Indemnification 10/2013 _2— FROM :BALL CHIROPPRACTIC CENTER FAX NO. :2536613610 Jan. 05 2015 03:33PM P2 01/05/2015 NON 15:11 WAX 1/0 0 2,I)u? _ �? CERTIFICATE OF LIABILITY INSURANCE DATE NAPRO01 Y)� 01/08/201 S THIS CERTIPICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND OONPERS NO RIGHTS UPON THE CERTIFICATE MOL,OER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE cOVEFtACE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE Ole PRODUCER.AND 119E CERTIFICATE HOLDER. IMPORTANT: If the cartificete holder Is an ADDITIONAL INSURED,the pohley(lee)must be endorsed. if SUBROGATION I(WAIVED,subject to the terms and conditions of the pollen,certain policies May require an endorsement. A stetamant on this certificate does not confer rights to du oertlfIcete holder In lieu of such un ursement(s). PRODUCER Alliance West Insurance,Inc. O AMR Rabbles - - t1116 BrldgepoRWay SW, Ste.2 sty 126,9}814-L3TS 1 IWO.no 2 .glit- b_/4 _ Lakewood,WA 98498 au nlnnoeweelk►puranoe.com _ T,Icense#:7 3019 - S PPD NA QQYSt E NAIL i1 INSURED memos A 1 THEBARTFORD -.--, DCPB CORP INwRrit 4; DOA BALL CHIROPRACTIC CENTER AlIJJLRa: — SURE 1717 SOUTH 324TH ST STE B IN N°` -- _ — FEDERAL WAY,WA 98003 I" ��' — w —, IN., EN E COVERAGE8 CERTIPIC NU ATE MBER; o000B160-0 REVISION NUMBER: 1 THIS IS TO CERTIFY THAT T$s POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMRD ABOVE POR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RIOUIRIIMEnrT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMI_N1 WIN RESPECT Tc)WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANOr APPORDED BY THE EOUCIES DESCRIBED HEREIN 18 SUBJECT TO ALL YMs TENNIS. EXCL111910NS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN 10 SPLICED BY i�,11O PAID CLAIMS_ yi- TYPE oP INSURANCE EQIJOY ram= MAR#A0l I 7Y UNTO A °Rarnl,'AeILm Y 01 SBA AW6327 09107/201EI 011t17121315 SA1114 OCCURRENCE 1.000 0C O -CDAMAIR ru RAN IED I OMEAOIAL GENSKAL LIAOILRY 6101SER Fe nomnrnm) $ 60,0C B i CLMME.MADE ®OCCUR ME)EXP(AQy QIIA pawn) _3 10,00 t i PEnt©NA1.4 ASV INJURY_ $ 2.000,0()a GENERAL AGGREGATE $ 4,0QQAK 3 L AGGREGATE LIMIT APPUES PER' Fgapl TS-OOMPJOFAOQ,t 4.,000,00 L x l eouov[J 11 Leo 8 ALIWEADOILa LIABILITY Col a si L ANY AUTO BOIIIL'INJURY(Per venom u ALL U— AUTOS ED "U r.ULCG Bq�ELY INJURY IPNtamlAAnq .i HIRSD AUTOS AUr r� pip a UMBRELLA UAEI ,. ' OCCUR - �� S EA1;�rx�lag�NCE s !NotesI.IAt1 cLAIMS.MADE AociRel TE r WOR1�mRICOMPINEAfOrN Tf STAYU- 19k. f AND EMPLOYERS'LIANLITY yy�I NN _I j Y LrauTc � ANY PROPRIETOR/PARTNER/EXECUTIVE t N/A �i L�N ACCIDENT I ppF�FICERIM @MeL"R EXCLUDED? U IMEEIIMUTY IIN NNIII) El DISEASE•EA EMPLOYEE .1 IIf]Gb:CRIP?]AN UF4FehAT10pb pow, _4(1,.efOSE•POLICY OIL.0 DS$OaMTION of OPERATIONS I LOOATIONB'VEHICLE)IANAofl ACORD 101,ARIEhma1 RerlaM*64 •60e,If Here space N rorwirom THOSE USUAL TO THE INSUROD"8 QPERATTON9 ERTIFIC OL ER _2ANCELLATION .. CITY OF FEDERAL WAY TNe SHOULD ANY DATE TTHHERNOIIE�NOTICE WILL ER D L Vas n N D IITiFORE FEDERAL WAY COMUNITY CENTER ACCORDANCE WITH THE POLICY PROVi810N10. 878 SOUTH 333RD ST - FEDERAL WAY,WA 98003 Au QR n RA RIMS TAME � I r I The ACORD name sry I✓ ®1988-2090 ACORD CORPORATION, All rights resew(=I. ACORD 25 20101D5) ame and logo are raglatered marks of ACOFW printod 1.(5(JF1R on January OS,2015 at 03:09PN