HomeMy WebLinkAboutPK04-069 - Original - Pioneer Human Services - Multicultural Supervised Visitation & Exchange Center - 08/14/2003 KENT
WASHINOTON
CONSULTANT SERVICES AGREEMENT
between the City of Kent and
PIONEER HUMAN SERVICES
THIS AGREEMENT is made between the City of Kent, a Washington municipal corporation
(hereinafter the "City"), and Pioneer Human Services, Consulting Services Division, organized under the laws
of the State of Washington, located and doing business at 7440 W. Marginal Way South, Seattle, WA 98108,
(206) 768-1990(hereinafter the "Consultant").
I. DESCRIPTION OF WORK.
Consultant shall perform the following services for the City in accordance with the following described
plans and/or specifications:
Consultant shall evaluate the process for planning and implementing the opening of a
multicultural supervised visitation and exchange center for family violence victims within the
City of Kent. Hallie Goertz, MPA, shall serve as lead evaluator on this project. Larry M.
Fehr, MPA, shall serve as co-evaluator. The City's Grant Manager on this Agreement shall be
Dinah R. Wilson. The following exhibits are attached and incorporated by this reference as if
fully set forth herein: Exhibit A, Scope of Work; Exhibit B, Compensation and Payment Rates,
not to exceed $11,000 total; and Exhibit C,Billing Voucher to be used when invoicing the City.
Consultant further represents that the services furnished under this Agreement will be performed in
accordance with generally accepted professional practices in effect at the time those services are performed.
II. TIME OF COMPLETION. The parties agree that work will begin on the tasks described in
Section I above immediately upon the effective date of this Agreement. Upon the effective date of this
Agreement, Consultant shall complete the work described in Section I by December 31, 2003. An option for a
second one year term commencing on January 1, 2004 and ending December 31, 2004, is contingent upon the
availability of federal Deparment of Justice funds and the party's agreement to the required performance. In
addition, an option for a third one year term commencing on January 1, 2005 and ending on December 31,
2005, is contingent upon the availability of federal Deparment of Justice funds and the party's agreement to the
required performance. The renewal shall be completed upon execution of a Change Order prior to the
termination of this agreement and its current term.
III. COMPENSATION.
A. The City shall pay the Consultant, based on time and materials, an amount not to exceed 11,000
for the services described in this Agreement. This is the maximum amount to be paid under this
Agreement for the work described in Section I above, and shall not be exceeded without the prior
written authorization of the City in the form of a negotiated and executed supplemental
agreement. The Consultant agrees that the hourly or flat rate charged by it for its services
CONSULTANT SERVICES AGREEMENT- 1
(Over$10,000)
contracted for herein shall remain locked at the negotiated rate(s) for a period of one (1) year
from the effective date of this Agreement. The Consultant's billing rates shall be as delineated in
Exhibit B.
B. The Consultant shall submit quarterly payment invoices to the City for work performed, and a
final bill upon completion of all services described in this Agreement. The City shall provide
payment within forty-five (45) days of receipt of an invoice. If the City objects to all or any
portion of an invoice, it shall notify the Consultant and reserves the option to only pay that
portion of the invoice not in dispute. In that event, the parties will immediately make every
effort to settle the disputed portion.
IV. INDEPENDENT CONTRACTOR. The parties intend that an Independent Contractor-
Employer Relationship will be created by this Agreement and that the Consultant has the ability to control and
direct the performance and details of its work, the City being interested only in the results obtained under this
Agreement.
V. TERMINATION. Either party may terminate this Agreement, with or without cause, upon
providing the other party thirty (30) days written notice at its address set forth on the signature block of this
Agreement. After termination, the City may take possession of all records and data within the Consultant's
possession pertaining to this project, which may be used by the City without restriction. If the City's use of
Consultant's records or data is not related to this project, it shall be without liability or legal exposure to the
Consultant.
VI. DISCRIMINATION. In the hiring of employees for the performance of work under this
Agreement or any subcontract, the Consultant, its subcontractors, or any person acting on behalf of the
Consultant or subcontractor shall not, by reason of race, religion, color, sex, age, sexual orientation, national
origin, or the presence of any sensory, mental, or physical disability, discriminate against any person who is
qualified and available to perform the work to which the employment relates. Consultant shall execute the
attached City of Kent Equal Employment Opportunity Policy Declaration, Comply with City Administrative
Policy 1.2, and upon completion of the contract work, file the attached Compliance Statement.
VII. INDEMNIFICATION. Consultant shall defend, indemnify and hold the City, its officers,
officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or suits,
including all legal costs and attorney fees, arising out of or in connection with the Consultant's performance of
this Agreement, except for that portion of the injuries and damages caused by the City's negligence.
The City's inspection or acceptance of any of Consultant's work when completed shall not be grounds to
avoid any of these covenants of indemnification.
Should a court of competent jurisdiction determine that this Agreement is subject to RCW 4.24.115,
then, in the event of liability for damages arising out of bodily injury to persons or damages to property caused
by or resulting from the concurrent negligence of the Consultant and the City, its officers, officials, employees,
agents and volunteers, the Consultant's liability hereunder shall be only to the extent of the Consultant's
negligence.
IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE
INDEMNIFICATION PROVIDED HEREIN CONSTITUTES THE CONSULTANT'S WAIVER OF
IMMUNITY UNDER INDUSTRIAL INSURANCE, TITLE 51 RCW, SOLELY FOR THE PURPOSES OF
THIS INDEMNIFICATION. THE PARTIES FURTHER ACKNOWLEDGE THAT THEY HAVE
MUTUALLY NEGOTIATED THIS WAIVER.
CONSULTANT SERVICES AGREEMENT-2
(Over$10,000)
h h R
The provisions of this section shall survive the expiration or termination of this Agreement.
VIM INSURANCE. The Consultant shall procure and maintain for the duration of the Agreement,
insurance of the types and in the amounts described in Exhibit D attached and incorporated by this reference.
IX. EXCHANGE OF INFORMATION. The City will provide its best efforts to provide
reasonable accuracy of any information supplied by it to Consultant for the purpose of completion of the work
under this Agreement.
X. OWNERSHIP AND USE OF RECORDS AND DOCUMENTS. Original documents,
drawings, designs, reports, or any other records developed or created under this Agreement shall belong to and
become the property of the City. All records submitted by the City to the Consultant will be safeguarded by the
Consultant. Consultant shall make such data, documents, and files available to the City upon the City's request.
The city's use or reuse of any of the documents, data and files created by Consultant for this project by anyone
other than Consultant on any other project shall be without liability or legal exposure to Consultant.
XI. CITY'S RIGHT OF INSPECTION. Even though Consultant is an independent contractor
with the authority to control and direct the performance and details of the work authorized under this
Agreement, the work must meet the approval of the City and shall be subject to the City's general right of
inspection to secure satisfactory completion.
XII. WORK PERFORMED AT CONSULTANT'S RISK. Consultant shall take all necessary
precautions and shall be responsible for the safety of its employees, agents, and subcontractors in the
performance of the contract work and shall utilize all protection necessary for that purpose. All work shall be
done at Consultant's own risk, and Consultant shall be responsible for any loss of or damage to materials, tools,
or other articles used or held for use in connection with the work.
XIII. MISCELLANEOUS PROVISIONS.
A. Recyclable Materials. Pursuant to Chapter 3.80 of the Kent City Code, the City requires its
contractors and consultants to use recycled and recyclable products whenever practicable. A price preference
may be available for any designated recycled product.
B. Non-Waiver of Breach. The failure of the City to insist upon strict performance of any of the
covenants and agreements contained in this Agreement, or to exercise any option conferred by this Agreement
in one or more instances shall not be construed to be a waiver or relinquishment of those covenants, agreements
or options, and the same shall be and remain in full force and effect.
C. Resolution of Disputes and Governing Law. This Agreement shall be governed by and
construed in accordance with the laws of the State of Washington. If the parties are unable to settle any dispute,
difference or claim arising from the parties' performance of this Agreement, the exclusive means of resolving
that dispute, difference or claim, shall only be by filing suit exclusively under the venue, rules and jurisdiction
of the King County Superior Court, King County, Washington, unless the parties agree in writing to an
alternative dispute resolution process. In any claim or lawsuit for damages arising from the parties'
performance of this Agreement, each party shall pay all its legal costs and attorney's fees incurred in defending
or bringing such claim or lawsuit, in addition to any other recovery or award provided by law; provided,
however, nothing in this paragraph shall be construed to limit the City's right to indemnification under Section
VII of this Agreement.
CONSULTANT SERVICES AGREEMENT.3
(Over$10,000)
D. Written Notice. All communications regarding this Agreement shall be sent to the parties at the
addresses listed on the signature page of the Agreement, unless notified to the contrary. Any written notice
hereunder shall become effective three(3)business days after the date of mailing by registered or certified mail,
and shall be deemed sufficiently given if sent to the addressee at the address stated in this Agreement or such
other address as may be hereafter specified in writing.
E. Assignment. Any assignment of this Agreement by either party without the written consent of
the non-assigning party shall be void. If the non-assigning party gives its consent to any assignment, the terms
of this Agreement shall continue in full force and effect and no further assignment shall be made without
additional written consent.
F. Modification. No waiver, alteration, or modification of any of the provisions of this Agreement
shall be binding unless in writing and signed by a duly authorized representative of the City and Consultant.
G. Entire Agreement. The written provisions and terms of this Agreement, together with any
Exhibits attached hereto, shall supersede all prior verbal statements of any officer or other representative of the
City, and such statements shall not be effective or be construed as entering into or forming a part of or altering
in any manner this Agreement. All of the above documents are hereby made a part of this Agreement.
However, should any language in any of the Exhibits to this Agreement conflict with any language contained in
this Agreement,the terms of this Agreement shall prevail.
H. Compliance with Laws. The Consultant agrees to comply with all federal, state, and municipal
laws, rules, and regulations that are now effective or in the future become applicable to Consultant's business,
equipment, and personnel engaged in operations covered by this Agreement or accruing out of the performance
of those operations.
IN WITNESS,the parties below execute this Agreement,which shall become effective on the last
date entered below.
CONSULTANT: CITY OIr KENT:
By: By:
stgn"e) (signature)
Print Name: M aei J.Burns Print e: Jim White
Its: President/CEO Its: Mayor
ule) (Tile) /
DATE: 1 � 2 DATE: /�—Q3
NOTICES TO BE SENT TO: NOTICES TO BE SENT TO:
CONSULTANT: CITY OF KENT:
Hallie Goertz, MPA Katherin Johnson, Human Services Manager
Pioneer Human Services City of Kent
Director of Integration, Evaluation&Development 220 Fourth Avenue South
7440 W. Marginal Way South Kent, WA 98032
Seattle,WA 98108
(206) 768-1990 (telephone) (253) 856-5073 (telephone)
(206) 768-8910 (facsimile) (253) 856-6070 (facsimile)
206)448-5766 facsimile
CONSULTANT SERVICES AGREEMENT-4
(Over$10,000)
APPROVED AS TO FORM:
,&Ak I�tk 6LU,
Kent City Attorney
CONSULTANT SERVICES AGREEMENT-5
(Over$10,000)
� 4 1
DECLARATION
CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY POLICY
The City of Kent is committed to conform to Federal and State laws regarding equal opportunity. As such all
contractors, subcontractors and suppliers who perform work with relation to this Agreement shall comply with
the regulations of the City's equal employment opportunity policies.
The following questions specifically identify the requirements the City deems necessary for any contractor,
subcontractor or supplier on this specific Agreement to adhere to. An affirmative response is required on all of
the following questions for this Agreement to be valid and binding. If any contractor, subcontractor or supplier
willfully misrepresents themselves with regard to the directives outlines, it will be considered a breach of
contract and it will be at the City's sole determination regarding suspension or termination for all or part of the
Agreement;
The questions are as follows:
1. I have read the attached City of Kent administrative policy number 1.2.
2. During the time of this Agreement I will not discriminate in employment on the basis of sex,race, color,
national origin, age, or the presence of all sensory,mental or physical disability.
3. During the time of this Agreement the prime contractor will provide a written statement to all new
employees and subcontractors indicating commitment as an equal opportunity employer.
I
4. During the time of the Agreement I,the prime contractor, will actively consider hiring and promotion of
women and minorities.
5. Before acceptance of this Agreement, an adherence statement will be signed by me, the Prime
Contractor,that the Prime Contractor complied with the requirements as set forth above.
By signing below, I agree to fulfill the five requirements referenced above.
Dated this day of .2005 .
By:
For:
Title:
Date:
EEO COMPLIANCE DOCUMENTS- 1
CITY OF KENT
ADMINISTRATIVE POLICY
NUMBER: 1.2 EFFECTIVE DATE: January 1, 1998
SUBJECT: MINORITY AND WOMEN SUPERSEDES: April 1, 1996
CONTRACTORS APPROVED BY Jim White,Mayor
POLICY:
Equal employment opportunity requirements for the City of Kent will conform to federal and state laws. All
contractors, subcontractors, consultants and suppliers of the City must guarantee equal employment opportunity
within their organization and, if holding Agreements with the City amounting to $10,000 or more within any
given year, must take the following affirmative steps:
1. Provide a written statement to all new employees and subcontractors indicating commitment as an equal
opportunity employer.
2. Actively consider for promotion and advancement available minorities and women.
Any contractor, subcontractor, consultant or supplier who willfully disregards the City's nondiscrimination and
equal opportunity requirements shall be considered in breach of contract and subject to suspension or
termination for all or part of the Agreement.
Contract Compliance Officers will be appointed by the Directors of Planning, Parks, and Public Works
Departments to assume the following duties for their respective departments.
1. Ensuring that contractors, subcontractors, consultants, and suppliers subject to these regulations are
familiar with the regulations and the City's equal employment opportunity policy.
2. Monitoring to assure adherence to federal, state and local laws,policies and guidelines.
EEO COMPLIANCE DOCUMENTS-2
CITY OF KENT
EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT
This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the
Agreement.
I,the undersigned, a duly represented agent of Company, hereby
acknowledge and declare that the before-mentioned company was the prime contractor for the Agreement
known as that was entered into on the (date)-.
between the firm I represent and the City of Kent.
I declare that I complied fully with all of the requirements and obligations as outlined in the City of Kent
Administrative Policy 1.2 and the Declaration City of Kent Equal Employment Opportunity Policy that was part
of the before-mentioned Agreement.
Dated this day of ,200_
By:
For:
Title:
Date:
EEO COMPLIANCE DOCUMENTS-3
EXHIBIT A
SCOPE AND SCHEDULE OF WORK
2003
CONSULTANT SERVICES AGREEMENT
Pioneer Human Services--Consulting Services Division
Safe Havens Grant Evaluator
SCOPE OF WORK
The purpose of this agreement is to procure consultant services to evaluate the process for planning
and implementing the opening of a multicultural supervised visitation and exchange center for family
violence victims within the City of Kent. This project is funded by U.S. Department of Justice, Office
of Justice Programs, Office on Violence Against Women. During the term of this agreement, the
consultant (evaluator) shall:
A. Gather and manage data collected for the planning and opening of a supervised visitation and
exchange center. Instruct staff in methods of qualitative data gathering to document the
process of program development.
B. Conduct individual and focus group interviews and/or community needs assessment if called
for in an evaluation plan developed in collaboration with the local program and Safe Havens
partners.
C. Work collaboratively and cooperatively with national evaluators, other local evaluators, Office
on Violence Against Women (OVW)and technical assistance providers to design and
implement local and national evaluation plans.
D. Work with Multi-Cultural Project Coordinator to design evaluation methods that are accessible
to limited English proficient and non-English speaking clients.
E. Document access of services for underserved populations.
F. Evaluate the effectiveness of guidelines, standards, training and/or promising practices
implemented in Safe Havens project in evaluation studies developed in collaboration with the
local program, National Evaluation Coordinators, and other partners.
G. Help to design evaluation tools for the project if necessary.
H. Conduct surveys of client perceptions of program if not performed through national evaluation.
I. Attend regularly scheduled Safe Havens Advisory Committee meetings.
J. Meet with Safe Havens Grant Manager on a regular basis, at least quarterly.
K. Maintain ongoing communication with Safe Havens Grant Manager; i.e., telephone and
electronic.
L. Provide written/oral updates on work to Safe Havens Grant Manager, Advisory Committee,
Kent City Council Committee or Full Council, and other City Departments as requested.
M. Participate in technical assistance and consultation via meetings and conference calls.
N. Participate in conference calls with national evaluators, at least quarterly.
O. Participate in site specific and project director conference calls as needed.
P. Participate in site visit meetings.
Q. Participate in training.
R. Coordinate evaluation process with the community safety audit process.
S. Submit draft written research reports and other materials produced pursuant to the Safe
Havens Grant Project to City, OVW, and national evaluators for review and approval.
T. Adhere to ethical and legal safeguards that must be applied when conducting research and
evaluations in the area of violence against women and children. Protect the confidentiality of
identifiable research and statistical information in compliance with 28 CFR Part 22 (see
attached)and have evaluation plans approved by appropriate Human Subjects Committees
prior to gathering data.
1
Note: This program does not provide direct services to clients; however outcomes will be
measured by whether the evaluator's activities assist in accomplishing grant objectives.
Outcome(s)
• Increase access to supervised visitation and exchange services for low and moderate-income
victims of family violence who reside in the Kent/South King County area.
• Increase access to culturally sensitive visitation and exchange services for ethnictracial minorities.
• Identify model standards of practice for supervised visitation and exchange services that are
responsive to the needs of women and children victims of family violence.
• Identify security procedures to create a visitation and exchange center that is safe for victims of
family violence.
• Increase communication between the court and the supervised visitation and exchange program
to ensure court compliance and victim safety.
• Increase referral to appropriate ancillary services.
Budget:
Consultant Activities $7,500
Travel $2,200
Clerical Support $750
Supplies $350
Phone/Fax $100
Postage $100
Total $11,000
Reportina Requirements and Timeline
The agency will be reimbursed on a quarterly basis, upon submittal of appropriate documentation. Such
documentation will include the following (as applicable): Billing Voucher (Exhibit C) itemizing the work that was
done, number of hours worked, the hourly rate charged, etc . Billing must be submitted on forms provided by the
City by the 10'"of the following month for the previous quarter of service.The reporting timeline is as follows:
Billing Voucher(Exhibit C) 10'H day following each quarter
Final Billing Voucher(December Exhibit C) December 31,2003
Activities Accomplished &How the Evaluator's January 31,2004
Activities Assist in Accomplishing Grant Objectives
(Written Report)
Pursuant to Item I. of the Consultant Services Agreement executed in August 2003, PHS shall submit
the following supplemental reports to demonstrate increased safety for family violence victims:
Supplemental Resorts
• Quarterly report summarizing activities accomplished and progress toward meeting the outcomes
outlined above (written report).
Contract Administration and Management
The Consultant shall notify the City, in writing, within (10) days of any changes in project personnel.
No changes in personnel shall be binding unless in writing and signed by a duly authorized
representative of the City and Consultant.
2
The above services shall be provided by December 31, 2003.
2003 Reimbursement: $11,000
Please sign to indicate acceptance of the Year 2003 Performance Measures listed above.
Michae reside Date
Kather ohnson, Human Services Manager Date
3
28 CFR Part 22 Confidentiality of Identifiable Research and Statistical Informatio... Page 1 of 7
28 CFR Part 22 Confidentiality of
Identifiable Research and Statistical
�Y Information (Regulations)
PLOLOMAC3 Code of Federal Regulations
Title 28 Volume 1,Parts 0 to 42
AIWiX NJ Revised as of July 1, 1999
From the U.S. Government Printing Office via GPO Access
415W CITE: 28CFR22.1
TITLE 28--JUDICIAL ADMINISTRATION
CHAPTER I--DEPARTMENT OF JUSTICE
PART 22--CONFIDENTIALITY OF IDENTIFIABLE RESEARCH AND
STATISTICAL INFORMATION--Table of Contents
Sec. 22.1 Purpose.
The purpose of these regulations is to:
(a)Protect privacy of individuals by requiring that information
identifiable to a private person obtained in a research or statistical
program may only be used and/or revealed for the purpose for which
obtained;
(b)Insure that copies of such information shall not, without the
consent of the person to whom the information pertains,be admitted as
evidence or used for any purpose in any judicial or administrative
proceedings;
(c)Increase the credibility and reliability of federally-supported
research and statistical findings by minimizing subject concern over
subsequent uses of identifiable information;
(d) Provide needed guidance to persons engaged in research and
statistical activities by clarifying the purposes for which identifiable
information may be used or revealed; and
(e) Insure appropriate balance between individual privacy and
essential needs of the research community for data to advance the state
of knowledge in the area of criminal justice.
(f)Insure the confidentiality of information provided by crime
victims to crisis intervention counselors working for victim services
programs receiving funds provided under the Crime Control Act, and
Juvenile Justice Act, and the Victims of Crime Act.
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[41 FR 54846,Dec. 15, 1976, as amended at 51 FR 6400, Feb. 24, 1986]
[Code of Federal Regulations]
[Title 28 Volume 1,Parts 0 to 42]
[Revised as of July 1, 1999]
From the U.S. Government Printing Office via GPO Access
Sec. 22.2 Definitions.
(a)Person means any individual,partnership, corporation,
association,public or private organization or governmental entity, or
combination thereof.
(b) Private person means any person defined in Sec. 22.2(a) other
than an agency, or department of Federal, State, or local government, or
any component or combination thereof. Included as a private person is an
individual acting in his or her official capacity.
(c)Research or statistical project means any program,project, or
component thereof which is supported in whole or in part with funds
appropriated under the Act and whose purpose is to develop, measure,
evaluate, or otherwise advance the state of knowledge in a particular
area. The term does not include "intelligence" or other information-
gathering activities in which information pertaining to specific
individuals is obtained for purposes directly related to enforcement of
the criminal laws.
(d) Research or statistical information means any information which
is collected during the conduct of a research or statistical project and
which is intended to be utilized for research or statistical purposes.
The term includes information which is collected directly from the
individual or obtained from any agency or individual having possession,
knowledge, or control thereof.
(e) Information identifiable to a private person means information
which either--
(1) Is labelled by name or other personal identifiers, or
(2) Can, by virtue of sample size or other factors, be reasonably
interpreted as referring to a particular private person.
(f)Recipient of assistance means any recipient of a grant,
contract, interagency agreement, subgrant, or subcontract under the Act
and any person, including subcontractors,employed by such recipient in
connection with performances of the grant, contract,or interagency
agreement.
(g) Officer or employee of the Federal Government means any person
employed as a regular or special employee of the U.S. (including
experts, consultants, and advisory board members)as of July 1, 1973, or
at any time thereafter.
(h) The act means the Omnibus Crime Control and Safe Streets Act of
1968, as amended.
(i)Applicant means any person who applies for a grant, contract, or
subgrant to be funded pursuant to the Act.
0)The Juvenile Justice Act means the "Juvenile Justice and
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28 CFR Part 22 Confidentiality of Identifiable Research and Statistical Informatio... Page 3 of 7
Delinquency Prevention Act of 1974, as amended."
(k) The Victims of Crime Act means the Victims of Crime Act of 1984.
[41 FR 54846, Dec. 15, 1976, as amended at 43 FR 16974,Apr. 21, 1978;
51 FR 6400, Feb. 24, 1986]
Sec. 22.20 Applicability.
(a)These regulations govern use and revelation of research and
statistical information obtained, collected, or produced either directly
by BJA, OJJDP,BJS,NIJ, or OJP or under any interagency agreement,
grant, contract, or subgrant awarded under the Crime Control Act, the
Juvenile Justice Act, and the Victims of Crime Act.
(b) The regulations do not apply to any records from which
identifiable research or statistical information was originally
obtained; or to any records which are designated under existing statutes
as public; or to any information extracted from any records designated
as public.
(c)The regulations do not apply to information gained regarding
future criminal conduct.
[41 FR 54846, Dec. 15, 1976, as amended at 43 FR 16974,Apr. 21, 1978;
51 FR 6400, 6401, Feb. 24, 1986]
Sec. 22.21 Use of identifiable data.
Research or statistical information identifiable to a private person
may be used only for research or statistical purposes.
Sec. 22.22 Revelation of identifiable data.
(a) Except as noted in paragraph(b) of this section,research and
statistical information relating to a private person may be revealed in
identifiable form on a need-to-know basis only to--
(1) Officers, employees, and subcontractors of the recipient of
assistance;
(2) Such individuals as needed to implement sections 202(c)(3), 801,
and 811(b) of the Act; and sections 223(a)(12)(A),223(a)(13),
223(a)(14),and 243 of the Juvenile Justice and Delinquency Prevention
Act.
(3) Persons or organizations for research or statistical purposes.
Information may only be transferred for such purposes upon a clear
demonstration that the standards of Sec. 22.26 have been met and that,
except where information is transferred under paragraphs (a) (1) and(2)
of this section, such transfers shall be conditioned on compliance with
a Sec. 22.24 agreement.
(b) Information may be revealed in identifiable form where prior
consent is obtained from an individual or where the individual has
agreed to participate in a project with knowledge that the findings
cannot, by virtue of sample size, or uniqueness of subject,be expected
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28 CFR Part 22 Confidentiality of Identifiable Research and Statistical Informatio... Page 4 of 7
to totally conceal subject identity.
[41 FR 54846,Dec. 15, 1976, as amended at 51 FR 6400, Feb. 24, 1986]
Sec. 22.23 Privacy certification.
(a) Each applicant for BJA, OJJDP, BJS,NIJ, or OJP support either
directly or under a State plan shall submit a Privacy Certificate as a
condition of approval of a grant application or contract proposal which
has a research or statistical project component under which information
identifiable to a private person will be collected.
(b) The Privacy Certificate shall briefly describe the project and
shall contain assurance by the applicant that:
(1) Data identifiable to a private person will not be used or
revealed, except as authorized under Secs. 22.21, 22.22.
(2)Access to data will be limited to those employees having a need
therefore and that such persons shall be advised of and agree in writing
to comply with these regulations.
(3) All subcontracts which require access to identifiable data will
contain conditions meeting the requirements of Sec. 22.24.
(4) To the extent required by Sec. 22.27 any private persons from
whom identifiable data are collected or obtained, either orally or by
means of written questionnaire, shall be advised that the data will only
be used or revealed for research or statistical purposes and that
compliance with requests for information is not mandatory. Where the
notification requirement is to be waived,pursuant to Sec. 22.27(c), a
justification must be included in the Privacy Certificate.
(5) Adequate precautions will be taken to insure administrative and
physical security of identifiable data.
(6)A log will be maintained indicating that identifiable data have
been transmitted to persons other than BJA, OJJDP,BJS,NIJ, or OR or
grantee/contractor staff or subcontractors, that such data have been
returned, or that alternative arrangements have been agreed upon for
future maintenance of such data.
(7) Project plans will be designed to preserve anonymity of private
persons to whom information relates, including,where appropriate,name-
stripping, coding of data, or other similar procedures.
(8) Project findings and reports prepared for dissemination will not
contain information which can reasonably be expected to be identifiable
to a private person except as authorized under Sec. 22.22.
(c) The applicant shall attach to the Privacy Certification a
description of physical and/or administrative procedures to be followed
to insure the security of the data to meet the requirements of
Sec. 22.25.
[41 FR 5486, Dec. 15, 1976, as amended at 51 FR 6401, Feb. 24, 1986]
Sec. 22.24 Information transfer agreement.
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Prior to the transfer of any identifiable information to persons
other than BJA, OJJDP,BJS,NIJ, or OJP or project staff, an agreement
shall be entered into which shall provide, as a minimum, that the
recipient of data agrees that:
(a)Information identifiable to a private person will be used only
for research and statistical purposes.
(b)Information identifiable to a private person will not be
revealed to any person for any purpose except where the information has
already been included in research findings (and/or data bases) and is
revealed on a need-to-know basis for research or statistical purposes,
provided that such transfer is approved by the person providing
information under the agreement, or authorized under Sec. 22.24(e).
(c)Knowingly and willfully using or disseminating information
contrary to the provisions of the agreement shall constitute a violation
of these regulations,punishable in accordance with the Act.
(d) Adequate administrative and physical precautions will be taken
to assure security of information obtained for such purpose.
(e)Access to information will be limited to those employees or
subcontractors having a need therefore in connection with performance of
the activity for which obtained, and that such persons shall be advised
of, and agree to comply with,these regulations.
(f)Project plans will be designed to preserve anonymity of private
persons to whom information relates, including,where appropriate,
required name-stripping and/or coding of data or other similar
procedures.
(g)Project findings and reports prepared for dissemination will not
contain information which can reasonably be expected to be identifiable
to a private person.
(h) Information identifiable to a private person(obtained in
accordance with this agreement) will,unless otherwise agreed upon,be
returned upon completion of the project for which obtained and no copies
of that information retained.
[41 FR 5486, Dec. 15, 1976, as amended at 51 FR 6401, Feb. 24, 1986]
Sec. 22.25 Final disposition of identifiable materials.
Upon completion of a research or statistical project the security of
identifiable research or statistical information shall be protected by:
(a) Complete physical destruction of all copies of the materials or
the identifiable portion of such materials after a three-year required
recipient retention period or as soon as authorized by law, or
(b) Removal of identifiers from data and separate maintenance of a
name-code index in a secure location.
The Privacy Certificate shall indicate the procedures to be followed and
shall, in the case of paragraph(b) of this section,describe procedures
to secure the name index.
Sec. 22.26 Requests for transfer of information.
http://www.ojp.usdoj.gov/nij/humansubjects/hs_IO.htmi 7/14/2003
28 CFR Part 22 Confidentiality of Identifiable Research and Statistical Informatio... Page b or i
(a)Requests for transfer of information identifiable to an
individual shall be submitted to the person submitting the Privacy
Certificate pursuant to Sec. 22.23.
(b)Except where information is requested by BJA, OJJDP,BJS,NIJ,
or OJP,the request shall describe the general objectives of the project
for which information is requested, and specifically justify the need
for such information in identifiable form. The request shall also
indicate, and provide justification for the conclusion that conduct of
the project will not, either directly or indirectly,cause legal,
economic,physical,or social harm to individuals whose identification
is revealed in the transfer of information.
(c)Data may not be transferred pursuant to this section where a
clear showing of the criteria set forth above is not made by the person
requesting the data.
[41 FR 5486,Dec. 15, 1976, as amended at 51 FR 6401,Feb. 24, 1986]
Sec. 22.27 Notification.
(a)Any person from whom information identifiable to a private
person is to be obtained directly, either orally, by questionnaire, or
other written documents, shall be advised:
(1) That the information will only be used or revealed for research
or statistical purposes; and
(2) That compliance with the request for information is entirely
voluntary and may be terminated at any time.
(b) Except as noted in paragraph(c) of this section,where
information is to be obtained through observation of individual activity
or performance,such individuals shall be advised:
(1) Of the particular types of information to be collected;
(2)That the data will only be utilized or revealed for research or
statistical purposes; and
(3) That participation in the project in question is voluntary and
may be terminated at any time.
(c)Notification, as described in paragraph(b)of this section, may
be eliminated where information is obtained through field observation of
individual activity or performance and in the judgment of the researcher
such notification is impractical or may seriously impede the progress of
the research.
(d) Where findings in a project cannot,by virtue of sample size, or
uniqueness of subject, be expected to totally conceal subject identity,
an individual shall be so advised.
Sec. 22.28 Use of data identifiable to a private person for judicial,
legislative or administrative purposes.
(a)Research or statistical information identifiable to a private
person shall be immune from legal process and shall only be admitted as
evidence or used for any purpose in any action, suit, or other judicial,
http://www.ojp.usdoj.gov/nij/humansubjects/hs_10.html 7/14/2003
28 CFR Part 22 Confidentiality of Identifiable Research and Statistical Informatio... Page 7 of 7
legislative or administrative proceeding with the written consent of the
individual to whom the data pertains.
(b) Where consent is obtained, such consent shall:
(1)Be obtained at the time that information is sought for use in
judicial, legislative or administrative proceedings;
(2) Set out specific purposes in connection with which information
will be used;
(3)Limit,where appropriate,the scope of the information subject
to such consent.
[41 FR 54846,Dec. 15, 1976, as amended at 45 FR 62038, Sept. 18, 1980)
Sec. 22.29 Sanctions.
Where BJA, OJJDP, BJS,NIJ, or OJP believes that a violation has
occurred of section 812(a)of the Act or section 1407(d) of the Victims
of Crime Act, these regulations, or any grant or contract conditions
entered into thereunder, it may initiate administrative actions leading
to termination of a grant or contract, commence appropriate personnel
and/or other procedures in cases involving Federal employees, and/or
initiate appropriate legal actions leading to imposition of a fine of
not to exceed$10,000 against any person responsible for such
violations.
[41 FR 54846,Dec. 15, 1976, as amended at 45 FR 62038, Sept. 18, 1980;
51 FR 6401, Feb. 24, 1986]
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EXHIBIT B
COMPENSATION AND PAYMENT
A. Amount of Compensation: Total compensation payable to Consultant for
satisfactory performance of work under this Agreement is a maximum of
$11,000.' Funds are awarded under this Agreement from the Office on
Violence Against Women (Department of Justice, Office of Justice
Programs), Award Number 2003-CW-BX-KO01. The Project Title is Safe
Havens: Supervised Visitation and Safe Exchange Program. Consultant's
compensation for services rendered under this Agreement shall be based on
the following rates or in accordance with the following terms:
• Evaluation Activities: $50 per hour for evaluation activities (i.e., managing
and gathering data, focus group interviewing, needs assessments,
conducting and designing client surveys,written research reports,
training/instruction, evaluation design, documentation of service access,
development of collection tools/evaluation methods, designing evaluation
methods that are accessible to limited English proficient and non-English
speaking clients, evaluation of promising practices, and coordination of
evaluation process with safety audit process).
• Coordination Activities: $50 per hour for coordination activities (i.e.,
working collaboratively with national evaluators, other local evaluators,
OVW, and technical assistance providers, attending Safe Havens
Advisory Committee meetings/site visit meetings, participating in
conference calls scheduled by the national evaluators, site-specific
conference calls, project director conference calls, and technical
assistance and consultation via phone and electronic mail).
• In-Person Consultations/Meetings: $50 per hour for in-person
consultations with Safe Havens Program Manager, up to a maximum of
four, two-hour consultations.
• Written/Oral Updates: $45 per hour to prepare/present written/oral
updates on work to Safe Havens Grant Manager, Advisory Committee,
Kent City Council Committee or Full Council, and other City Departments,
up to a maximum of seven hours per quarter.
• Telephone and Electronic Communication: $40 per hour for telephone
and electronic communication with Safe Havens Grant Manager, up to a
maximum of two hours per month.
• Training: $30 per hour to attend training? In addition to attending
compensated training, the Consultant shall attend a minimum of eight(8)
hours of uncompensated domestic violence training. Consultant shall
seek the City's approval before attending training. Consultant's eight
hour training requirement shall be completed prior to the expiration of this
Agreement.
' Pursuant to federal regulations, consultant rates shall not exceed$450 per day without prior
approval from the Department of Justice.
2 Training refers to events sponsored by OVW,technical assistance partners,the City of Kent or
grant collaborators. Uncompensated training can be sponsored by local or regional domestic
violence service provider agencies.
t
• Clerical: $30 per hour for clerical support, up to a maximum of 15 hours
per quarter.
• Travel Time: $20 per hour travel time up to a maximum of six hours per
day.
B. Expenses: Contractor shall receive reimbursement for travel and other
expenses as identified below or as authorized in advance by the City as
reimbursable. The maximum amount to be paid to Contractor for such
expenses is$2,750,which amount is included in the contract total in
Paragraph A. Such expenses include: airfare (economy or coach class only),
airport parking, ground transportation (maximum of$50 per out of town trip),
lodging (costs exceeding OVW negotiated rate, shall be pre-approved by
Safe Havens Grant Manager), meals (maximum of$50 per day), supplies,
phone/fax, and postage. Contractor shall be reimbursed for mileage at the
federal reimbursement rate, currently$0.36/mile.
C. Movement of Funds: Contractor may move up to ten percent(10%) of the
total compensation awarded under this Agreement between budget
categories provided there is no change in the scope of the evaluation project.
Cumulative changes which exceed 10% of the total compensation amount
require prior approval from the City.
D. Budget:
Consultant Activities (See A) $7,500
Travel and Per Diem $2,200
Clerical Support(See A) $ 750
Supplies $ 350
Phone/Fax $ 100
Postage $ 100
Total $11,000
2
EXHIBIT C
2003 Billing Voucher
SAFE HAVENS GRANT
To: Agency/Person:
Dinah Wilson Mailing Address:
Housing &Human Services
Parks Recreation &Community Services
220 4�'Ave. South, Kent,WA 98032
drwilson .a kent wa.us Telephone:
Phone: 253 856-5076 E-mail:
ITEMIZED BILLING*
I. CONSULTANT ACTIVITIES:
DATE WORK PERFORMED AMOUNT
Hrs./Rate_/ Total:
Hrs./Rate_! Total:
Hrs./Rate_! Total:
Hrs./Rate_! Total:
Hrs./Rate / Total:
Hrs./Rate_/ Total:
Hrs./Rate_/ Total:
Hrs./Rate_/ Total:
Hrs./Rate_/ Total:
Hrs./Rate I Total:
Hrs./Rate I Total:
Hrs./Rate_/ Total:
Hrs./Rate_/ Total:
Hrs./Rate_/ Total:
Hrs./Rate I Total:
Hrs./Rate_/ Total:
Hrs./Rate / Total:
TOTAL:
II. TRAVEL
DATE PURPOSE AMOUNT
TOTAL:
III. CLERICAL SUPPORT
DATE WORK PERFORMED AMOUNT
Hrs./Rate I Total:
Hrs./Rate_/ Total:
Hrs./Rate_I Total:
TOTAL:
IV. SUPPLIES
DATE ITEM AMOUNT
TOTAL:
V. PHONE/FAX
DATE PURPOSEICITY &STATE AMOUNT
TOTAL:
VI. POSTAGE
DATE DESCRIPTION AMOUNT
TOTAL:
Authorized Signature Date
FOR DEPARTMENT USE ONLY
AUTHORIZED FOR PAYMENT
BY: DATE:
*Receipts must be attached for expenses.
P
EXHIBIT D ` � `�
INSURANCE & INDEMNITY REQUIREMENTS FOR
CONSULTANT SERVICES AGREEMENTS
Indemnification/Hold Harmless
The Contractor shall defend,indemnify and hold the City,its officers, officials,
employees and volunteers harmless from any and all claims,injuries, damages, losses or
suits including attorney fees,arising out of or in connection with the performance of this
Agreement, except for injuries and damages caused by the sole negligence of the City.
Should a court of competent jurisdiction determine that this Agreement is subject to
RCW 4.24.115,then, in the event of liability for damages arising out of bodily injury to
persons or damages to property caused by or resulting from the concurrent negligence of
the Contractor and the City, its officers, officials,employees,and volunteers, the
Contractor's liability hereunder shall be only to the extent of the Contractor's negligence.
It is further specifically and expressly understood that the indemnification provided
herein constitutes the Contractor's waiver of immunity under Industrial Insurance,Title
51 RCW, solely for the purposes of this indemnification. This waiver has been mutually
negotiated by the parties. The provisions of this section shall survive the expiration or
termination of this Agreement.
Insurance
The Contractor shall procure and maintain for the duration of the Agreement,insurance
against claims for injuries to persons or damage to property which may arise from or in
connection with the performance of the work hereunder by the Contractor,their agents,
representatives, employees or subcontractors.
A, Minimum Scope of Insurance
Contractor shall obtain insurance of the types described below:
1. Commercial General Liability insurance shall be written on ISO
occurrence form CG 00 01 and shall cover liability arising from
premises, operations, independent contractors,products-completed
operations,personal injury and advertising injury,and liability
assumed under an insured contract. The Commercial General Liability
insurance shall be endorsed to provide the Aggregate Per Project
Endorsement ISO form CG 25 03 11 85. There shall be no
endorsement or modification of the Commercial General Liability
insurance for liability arising from explosion,collapse or underground
property damage. The City shall be named as an insured under the
Contractor's Commercial General Liability insurance policy with
respect to the work performed for the City using ISO additional
insured endorsement CG 20 10 1185 or a substitute endorsement
providing equivalent coverage.
2. Workers' Compensation coverage as required by the Industrial
Insurance laws of the State of Washington.
EXHIBIT D (Continued )
3. Professional Liability insurance appropriate to the Consultant's
profession.
B. Minimum Amounts of Insurance
Contractor shall maintain the following insurance limits:
1. Commercial General Liability insurance shall be written with limits no
less than$1,000,000 each occurrence, $1,000,000 general aggregate
and a $1,000,000 products-completed operations aggregate limit.
2. Professional Liability insurance shall be written with limits no less
than$1,000,000 per claim and$1,000,000 policy aggregate limit.
C. Other Insurance Provisions
The insurance policies are to contain, or be endorsed to contain,the following provisions
for Commercial General Liability insurance:
1. The Contractor's insurance coverage shall be primary insurance as respect the City.
Any Insurance, self-insurance, or insurance pool coverage maintained by the City
shall be excess of the Contractor's insurance and shall not contribute with it.
2. The Contractor's insurance shall be endorsed to state that coverage shall not be
cancelled by either party,except after thirty(30) days prior written notice by certified
mail, return receipt requested,has been given to the City.
3. The City of Kent shall be named as an additional insured on all policies (except
Professional Liability) as respects work performed by or on behalf of the contractor
and a copy of the endorsement naming the City as additional insured shall be attached
to the Certificate of Insurance. The City reserves the right to receive a certified copy
of all required insurance policies. The Contractor's Commercial General Liability
insurance shall also contain a clause stating that coverage shall apply separately to
each insured against whom claim is made or suit is brought, except with respects to
the limits of the insurer's liability.
D. Acceptability of Insurers
Insurance is to be placed with insurers with a current A.M.Best rating of not less than
AN II.
E. Verification of Coverage
Contractor shall furnish the City with original certificates and a copy of the amendatory
endorsements, including but not necessarily limited to the additional insured
endorsement,evidencing the insurance requirements of the Contractor before
commencement of the work.
EXHIBIT D (Continued)
F. Subcontractors
Contractor shall include all subcontractors as insureds under its policies or shall furnish
separate certificates and endorsements for each subcontractor. All coverages for
subcontractors shall be subject to all of the same insurance requirements as stated herein
for the Contractor.
Dre CERTIFICATE OF LIABILITY INSURANCE 06/30/2004 o�/os 2003)
tODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Loddon Companies ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Three City Place Drive,Suite 900 HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
St. Louis MO 63141-7081 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
(314)432.0500
INSURERS AFFORDING COVERAGE
BURIED INSURER Wesipart lnsuram&
)44216 Pioneer Human Services
Attn• Tracey Groscost INSURER B
7440 W.Marginal Way South INSURER C.
Seattle WA 98108
OVERAGES 62
rHE 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
V1AY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
'OLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
:B TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL UABIUTY EACH OCCURRENCE S 1,000,0()0
S X COMMERCIAL GENERAL LIABILITY TC3259276 06/30/2003 06/30/2004 FIRE DAMAGE(Anyone fire) $ 1000.000
CLAIMS MADE FXJ OCCUR MED EXP(Any oneersm $ 5,000
X INCL PROFESSIONAL PERSONAL 6 ADV INJURY $ 1 000 000
X INCL SEXUAL ABUSE GENERAL AGGREGATE $ 3 000 000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPOP ACG $ 3,000,000
POLI V PRO- F I L
AUTOMOBILE LIABILITY
ANY AUTO NOT APPLICABLE (Ea&COMBINED SINGLE LIMB s XXXXXXX
Ea cadeM)
ALL OWNED AUTOS BODILYper INJURt s XXXXXXX
pers
SCHEDULED AUTOS (Per on)
HIRED AUTOS
BODILY INJURY $ XXXXXXX
NON-OWNED AUTOS (PereCCfdert)tleM)
PROPERTY DAMAGE S XXXXXXX
(PeraccOW)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S XXXXXXX
11 ANY AUTO NOT APPLICABLE OTHER THAN EA ACC $ XXXXXXX
AUTO ONLY Acc S XXXXXXX
EXCESS LIABILITY EACH OCCURRENCE $ XXXXXXX
OCCUR ❑CLAIMS MADE NOT APPLICABLE AGGREGATE s XXXXXXX
E]UMBRELLA > XXXXXXX
DEDUCTIBLE FORM _ 5 }{XXXXxx
RETENTION $ S XXXXXXX
WORKERS COMPENSATION AND NOT APPLICABLE we srarU- DTH�_ _ -
c _
EMPLOYERS'LIABILITY E L EACH ACCIDENT S XXXXXXX
E L DISEASE EA EMPLOYEE $ XXXXXXX
E L DISEASE-POLICY LIMIT I$ XXXXXXX
OTHER
IESCRIPMON OF OPERATIONS?LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTBPECIAL PROVISIONS
CITY OF KENT IS ADDITIONAL INSURED UNDER GENERAL LIABILITY AS REQUIRED BY WRITTEN CONTRACT AS RESPECTS RESEARCH
AND EVALUATION SERVICES �rpp����{{yyE��a JUL 1 7
1`3L�CtIM AAir how& rSERVICEwr
'ERTIFICATE HOLDER ADDITIONAL INSURED INSURER LETTER:
1834351 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
HUMAN SERVICES DIVISION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
220 4TH AVE.,SOUTH
KENT WA 98032 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES
AUTHORIZED REPRESENTATIVE
%CORD 25-S(7/97) o ACORD CORPO ATION 1988
JUL-25-03 FRI 09:19 AM PIONEER HUMAN SERVICES iAX NU. U r, Ue
07/24/2003 1D:12 FAY 3148123129 1.00 rON INSURANCE Z001
LOCKTM
July 24,2{)03 Post-ir Fax Note 7671 Do oa r
From
coAlept DO
Ms, Tracey Groscust PhOM* PI]ww 4
Pioneer Human Servces Am
Fxa•
7440 W. Marginal Way South
Seattle, WA98108
Ke: Package Policy 4TC3259276
Policy Tenn, 06/30/03 to 06/30/04
Dear Tracey
As respects the Certificate of Insurance issued for City of Kent, Human Services Division
#1834151, we have requested Westport Insurance Company add them as an additional insured as
required by written contract for the above captioned policy,
Pleasc find attached a copy of our policy change request as documentation until the endolscment
has wren received. The original will be sent to you as soon as received As previously
mentioned Westport is very slow in issuing endorsements and it may take sornefune_
Tr,Wty, if you should need anything further, or have any questio]ts, please do not hesitate to
contact our offic"
:+inccrely,
L OCKTON COMPANIES
Matt a Fournier
Account Manager
Inxaf
Encioswes
t�'iCK]nNQsdPM�S()FS[I,WIS,W(.'
ictsua�cearcl ZdcN(tuw,yement Sporialsn
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h1fXlCV:F00.MttTpLLFM4.0.EAf1'IR+m] (114)412.0500/FAX p141313.3299
JUL-25-03 FR 109: 19 AM PIONEER HUMAN SERV 1 CE;S FAX NU. U V. Ud
07/24✓2003 10:12 FAX 3148123129 LOCKTON INSURANCE th002
OP )41 X(MYODf1 l
COMME12C�ROLtCY CHANGE t�E 01/23/03
PROlRhiEA_ )C............-._......_........._.............
Iyw mA Exy4- 314�432-0500 _. — _. 'ROPE ENERALLIASaITY x CPfi6
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_ _ _-----
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Westport Insura4TOAOa Co NAIccoDE _
•I)DE. (tDeCl)nE: _ _ _ p ------______�� _`rFssRcaulETEo. 1
cu .__.-- _ .._ �
WSURI<0'e NAME POLICY NUMBER EFFCMIVE DATE OF CHANCE
Pioneer Hur4an Sex.viaas TC3259276 06/30/03
!.'SURELYB NA4'Rv4 ADb1YL571 CNJINGIII)PMC Y!P-q •.- -• POIBCV N10EP1I011 DATE-._-_.- __-._-..�O Y EYPWATION DATE No. Mracey Croscoat 06/30/03 6/30/04
7440 W. M4xginal Way South 1-
Seattle WA 90100 THIS 4s AN ACK NOWLEDGP.NENT OF YOUR 1E9OEeT UI.ON APPROVAL.THE COMPANY{RECORDS III
OE ADJUSTED ACCORDINGLY.AND IF A PREMIUM ADJUSTMENT IS REOUI IT WILL BE DONE AT
PREMIUM AUDIT OR BY ENDORSEIAENT
PRGMISFS+lNfDRiMT10N ~ �y- - � ADD---
T� cHAND! DBMS:
1-CN:A rD1,0B r_�w STam LYTY.COUNTY.BTATET1Wa _CNY LIMITS e1TERBST I YRIUILTJ PARTOCL'UPED�_ _
i OUTSIDEt
TENANT
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MATURE OF 9USINE3St0P.SCMPT10N OF OPERATIORf9 BY PREMISE(S) AOO cxANDe DELETE
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WORK6.RS ci►iMPENSATION RATING INFORMATION
*OF ESFIMATED
MNASC 97ATE li LOr
CRTEDA DUTIES.CLASSIFICATION! EM ANNUAL"SC, USE
KOYEbs RlwNERATIM
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JUL-25-03 FRI 09:21 A11 PIONEER HUPIRN WVIUU) rMA RV, v
07J?4, 20G3 10.12 FAX 3148123129 LOCRTON INSURANCE Q003
ADDITMAL CHANGES AND REMARKS � �y PIOHU01
AS pigUArjD CXYLWiOtI'SI 'rEC �CT$PFI2 1'RES �' SCNBD CE RAN
FTCA ZONAL INSL"RED
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