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AG 15-024 *RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIV: PRCS/ q 2. ORIGINATING STAFF PERSON: _ gA �_ -� e EXT: 1 3 3. DATE REQ.BY: f no I a 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 fAM NDMENT AG#): ❑ INTERLOC L 0 OTHER 1V eM(i{ ICa 7r>�t— Pea_y4 [vI '� SA' �' r 4 5. PROJECT NAME: .i')1Il(� �f4� L ` S-64-(0,413 J✓( V 6. NAME OF CONTRACTOR: !�1DV tak Fnurt(L5.111 C'\ 2 i k ,, r ' C 3 TELEPHONE: G 5� 55-3 ADDRESS: >�zZ�'j l� l S'r- I,`�� S. -�P(Y Q.t�(A.� (,�.i(Q.t� 1 S�I�IJ� E-MAIL: J FAx: SIGNATURE NAME: D ICt 1A C {-f' CLu TITLE: OwY&-Y 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# ,JEXP. / /_ 8. TERM: COMMENCEMENT DATE: / 1 ' i`� COMPLETION DATE: � / I 1 I l l 9. TOTAL COMPENSATION:$ C) (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 REVIEWED INITIAL/DATE APPROVED 'PROJECT MANAGER `j 0-13 t � 4 ❑ SUPERVISOR ❑ DIRECTOR ❑ RISK MANAGEMENT (IF APPLICABLE) XLAW DEPT g 1/1571f 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 y4,SIGNATORY(MAYOR OR DIRECTOR) 4111W411117����% CITY CLERK // [�31�' ASSIGNED AG# A( •" SIGNED COPY RETURNED DATE SENT: ❑RETURN ONE ORIGINAL COMMENTS: 1 ep\aA ivks vvav V{ taS�- ce pet ui ce.r . -s U .ors- who a.u _ P at, 419-in i r-ft o -NY\ o1/u.1 4(y, i'1 11/9 a 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") t this Agreement are the City of Federal Way, a Washington municipal corporation("City") and \pry , a_("Health Care Provider"). ESQ 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 1 P.' r, • CITY OF FEDERAL WAY ATTEST Ar /I J._ Limn Jim Ferr ay r 1 , , -■ -' , CMC, Cit Clerk Date: Q-I1 I HEALTH CARE PROVIDER/VENDOR -'•nature) ‘ 40.)( AO crlduk, c FS Ilern (Printed Name and Title) for - (Organization Name) ga . I.o 0" nue_ S . \Z --. ONN (Address) (Phone) Date: I a"73v/ 1 Lei STATE OF WASHINGTON ) ) ss. COUNTY OF K.:-//19- ) On tlis day personally appeared before me Djcii i CAGlkf ;/} to me known to be the 0-f- - of -- j'4;C-r-> i-9c_4_, '-e, 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 301-41 day of .]ce,i-n bp , 201 , �'��F t, S 1 E g ', Notary's signatur /Jj Ge F 1.0'4; ti , Notary's print e%j0/7iCl_. L vim,�h�� b r, �' \4,s9°Al 9c t% Notary Public in and for the State of Washington. itts4is NOTARY ; p I My commission expires -.34,2-3/4-2. I, PUBLIC : v9��9/P912�_10. ,'. p=j ?!V./AS1A e� Health Fair Indemnification 10/2013 -2-