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AG 15-027 RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT/DIV: PRCS/ 2. ORIGINATING STAFF PERSON: s(t She, b�'\ EXT: 32 3. DATE REQ.BY: 1 �J 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 ND MENT #):1 INTERLOC L c , - i r OTHER y P m(1 rctivt 19 1- IA 5. PROJECT NAME: . ll� P(�L l-h,� J C CR I r 6. NAME OF CONTRACTOR: V I rqi 11 I (1."� �` tS'DbY` j�t'f z Q ADDRESS: 1 100 K)I M ' ih/€>€c f( .e U.J/ CC t f TELEPHONE: 2.S-3- Lo 2_ E-MAIL: FAX: SIGNATURE NAME: i4r t S- 04 v „L -vl TITLE: Di rf r - 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# ,IEXP. / / i 8. TERM: COMMENCEMENT DATE: I! Ti 1 I , COMPLETION DATE: I L i 1 L C 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 REVIEWED INITIAL/DATE APPROVED PROJECT MANAGER 1.ZA31 114 ❑ SUPERVISOR ❑ DIRECTOR ❑ RISK MANAGEMENT (IF APPLICABLE) ` LAW DEPT *17//r//f 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) ._3r_�7� CITY CLERK f J 1tI/M,iil ASSIGNED AG# Atr. t5-0A7 SIGNED COPY RETURNED DATE SENT: (AN 11 c ❑RETURN ONE ORIGINAL iC MME TS: PP 4ri 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 City of Federal Way, a Washington municipal corporation ("City") and V i d lYli4. I.A(,1sme\ , a 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 CITY OF FEDERAL WAY ATTEST 7-e'ifrfr7 /►T� 11.1 ,'T7 Jim Ferrel f ayo " •Neilly CMC, City s•k Date: I /� f 5' HEALTH CARE PROVIDER/VENDOR gCL (Signature) 11)rACt, C\1 Vr(3 P-rte 1 � Pect e ck (Printed Name and Title) V (-9 t ok Mots rM. (Organization Name) I )oo 10 1 -I1,1 -fie , Secc-K ,WA- c6c 14 I (Address) 743- Fs'LL—((o( 2 (Phone) Date: -44 - IL STATE OF WASHINGTON ) )ss. COUNTY OF _ On this day person. appeared before me 'i�c�5tax. C,{�r i� -}� e�5 to me known to be the kt,Mh1n; f of ®)∎r&i n c. MQS F.W. MA a i c.c.1 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 .41+k day of b2,C,2rn fir'' , 201 . NEOMA S. PHAIR STATE OF WASHINGTON Notary's signature S .P 1-1�lZ NOTARY PUBLIC Notary's printed name E o S. P}}p MY COMMISSION EXPIRES Notary Public in and for the State of Washington. 08-15-16 % My commission expires -/'1( , Health Fair Indemnification 10/2013 —2— ts, CERTIFICATE OF INSURANCE Insured: Virginia Mason Health System MS: G1-109 1100 Ninth Avenue,P.O.Box 900 Seattle,WA 98111 P:(206)583-6007 F:(206)515-5899 Coverages: Effective 05/31/2014 Virginia Mason Health System's Self-Insured Professional Liability Program covers the employees of Virginia Mason Health System while acting within the scope and during the course of their employment with Virginia Mason Health System,for all acts that are normally covered by customary general and professional liability insurance policies. This program is continuous and does not expire;however,termination of employment terminates coverage. Additional Insureds include students,employees and authorized volunteers when working for Virginia Mason Health System within the scope of their duties. This includes employed interns,externs,residents,certified registered nurse anesthetists,physician's assistants,dentists,osteopathic physicians and surgeons,physicians,podiatrists and surgeons,when working within the scope of their duties for Virginia Mason Health System. Type of Insurance: Limits: General Aggregate $ 1,000,000 General and Professional Liability: Products-Comp/Op Agg $ NIL Commercial General Liability,Medical Professional Personal&Adv Injury $ Included Liability Each Occurrence $ 1,000,000 Contractual Liability Fire Damage(Any one fire) $ Included Because this is self-insured by Virginia Mason Health Medical Expense(Any one System there is no"policy number" person) $ N/A Policy Effective Dates: Coverage provided by Virginia Mason Health System's Self-Insured Program is continuous and applicable to all general and professional liability claims occurring while the Virginia Mason Health System employs the provider irrespective of when a claim is made. Additional Description: Name of Event: Federal Way Health&Safety Fair Date of Event:January 17,2015 Location:876 South 333 Street; Federal Way,WA 98003 Certificate ate Issued with express authorization of Virginia Mason This document is conferred as information only,does not alter Health System,Director,Risk coverage afforded by the Self-Insurance Plan in any way,and guarantees the holder no rights beyond those extended in the policy. Certificate Issued To: City of Federal Way 876 S. 333rd St Federal Way,WA 98003 Date Issued: November 11,2014 LM/tlr Copies of this certificate should be considered equally valid to the original.