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AG 15-022 RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/Div: PRCS/ t 2. ORIGINATING STAFF PERSON: kt rvx - j She. t q EXT: 1 3 2_ 3. DATE REQ.BY: 17144 `J 4. TYPE OF DOCUMENT(CHECK ONE): o CONTRACTOR SELECTION DOCUMENT(E.G.,RFB,RFP,RFQ) o 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) o ORDINANCE ❑ RESOLUTION ❑ CONTRACT fAM NDMENT AG#): ❑ INTERLOC L (,� OTHER 11 d e m n i f �l (t'�— F f� I v i 1 1 ` cc'lS-c:- 1.( f 5. PROJECT NAME: tit/.j/L1.i 13 '1 c Ct-141 `. S `IeZ 6. NAME OF C O N T R A C T O R: . I/ C V't�i S 6 ADDRESS: 3. S ct-fk Ave S 'c°}` (ti/..J 'LV-) Uj TELEPHONE: y- l/v-c7 FAX: SIGNATURE NAME: 5 ct Yt(- TITLE: / r I.CL//LGZ.y--r" 7. EXHIBITS AND ATTACHMENTS: o 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. / / 8. TERM: COMMENCEMENT DATE: }/171 I I S COMPLETION DATE: ti t 1 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 o PURCHASING: PLEASE CHARGE TO: 10. DOCUMENT/CONTRACT REVIEW INITIAL/DATE VIEWED INITIAL/DATE APPROVED ,'PROJECT MANAGER 3 ‘"7-- 3 i t}4 ❑ SUPERVISOR ❑ DIRECTOR ❑ RISK MANAGEMENT (IF APPLICABLE) 3,AW DEPT I//f/ti 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) < CITY CLERK ASSIGNED AG# AGI ! 'C j SIGNED COPY RETURNED DATE SENT: t ❑RETURN ONE ORIGINAL COMMENTS: a S4 iltt1nn 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 (vitaltidi")sibitfiVAgreement are the City of Federal Way, a Washington municipal corporation("City") and 5•1 Fa rm.( S 1-)-OSpi+c1. I , 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 A Bement 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 CITY OF FEDERAL WAY ATTEST • ,V' 1 i Jim Ferrel ayor •• :r ' ' -' , CMC, Ca lerk Date: HEALTH CARE PROVIDER/VENDOR (Signature) KCt SC,bh t d + ) vbGJ r (Printed Name and Title) CR 1 nciScetn Hea l (Organization Name) SL1 SI S c kh Pi S0c4-!/, C.v P , CAA 98003 (Address) (Phone) t Date: II – 13 STATE OF WASHINGTON ) ) ss. COUNTY OF 6%,(11) ) On this day personally appeared before me 16 Sc Vl YV11ak- , to me known to be the \MO of \Ol u V�t� S2.�j'vt • that executed the foregoing instrument�Uknowledged 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 1� day of NNgi... V\ Oe� 20l L-1. Y ` ostImill Notary's signature he '/ �. / w ....- ��• ),P ••••..Thi,,. Notary's printed name TIL' //,�✓ ' IQ/01,44GU�I i. .•.••iiisIQN•. too iii ' ;off ;;. co y;A --- Notary Public in and for th State of Washington. v : N OTq R Y m.� My commission expires �,( S 22i 2015 'il: puglc �: a � �� . .•0�`� Health Fair Indemnification 10/2013 —2— FIRST INITIATIVES INSURANCE, LTD Governor's Square,Suite 4-213-4 23 Lime Tree Bay Ave., P.O.Box 10073 Grand Cayman,KY1-1001,Cayman Islands (345)943-2645,Fax(345)943-2646 Email: peterjones @cmi.ky THIS IS TO CERTIFY TO DATE OF CERTIFICATE ISSUANCE: January 8,2015 NAME AND ADDRESS OF CERTIFICATE HOLDER: ORIGINAL DATE OF ISSUANCE January 8,2015 CITY OF FEDERAL WAY ATTN:KIMBERLY SHELTON,COMMUNITY CENTER SUPERVISOR 876 S 333RD STREET • FEDERAL WAY,WA 98003 CERTIFICATE OF SELF-INSURANCE That the described self-insurance coverages as provided by the indicated policy and issued by the company has been issued to: Named Insured: ST FRANCIS HOSPITAL Address: 34515 NINTH AVENUE SOUTH FEDERAL WAY,WA 98003 The Policy identified below by a policy number is in force on the date of Certificate issuance.Self-Insurance is afforded only with respect to those coverages for which a specific limit of liability has been entered and is subject to all the terms of the Policy having reference thereto.This Certificate of Self-Insurance neither affirmatively nor negatively amends,extends or alters the coverage afforded under any policy identified herein. POLICY NUMBER POLICY PERIOD FIPR00714 EFF. 07/01/14 EXP. 07/01/15 TYPE OF SELF-INSURANCE DESIGNATED BELOW COVERAGES LIMITS OF LIABILITY BODILY INJURY,PROPERTY DAMAGE, PERSONAL INJURY LIABILITY& COMMERCIAL GENERAL LIABILITY MISCELLANEOUS PROFESSIONAL LIABILITY $10,000,000 Each claim HOSPITAL PROFESSIONAL LIABILITY AS DESCRIBED $10,000,000 Each claim $85,000,000 Shared Aggregate Claims made coverage.Policy retroactive date is: July 1,2002 SPECIAL CONDITIONS/OTHER COVERAGES ID NUMBER: 4605B CITY OF FEDERAL WAY IS ADDED AS ADDITIONAL INSURED,SUBJECT TO THE TERMS AND CONDITIONS OF THE POLICY,ATIMA,REGARDING THE FEDERAL WAY FAMILY HEALTH&SAFETY FAIR TO BE HELD ON 1/17/15. Cancellation:Should any of the above described policies be cancelled before the expiration date thereof,the issuing company will endeavor to mail 30 days written notice to the above named certificate holder,but failure to mail such notice shall impose no obligation or liability of any kind upon the company. CA°1444 ° uthorized Representative