HomeMy WebLinkAboutPK15-069 - Original - Pediatric Interim Care Center - Care of Drug Exposed Infants - 03/06/2015 i
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CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission
to City Clerks Office. All portions are to be completed.
If you have questions, please contact City Clerk's Office.
Vendor Name: Pediatric Interim Care Center
Vendor Number: 73861
JD Edwards Number
Contract Number: E is,-o L.l"l
This is assigned by City Clerk's Office
Project Name: Infant Care
Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment ® Contract
❑ Other:
i
Contract Effective Date: 1/1/2015 Termination Date: 12/31/2016
Contract Renewal Notice (Days): 30
Number of days required notice for termination or renewal or amendment
Contract Manager: Christine Cain Department: Parks - Human Services
Contract Amount: $10,000
Approval Authority: (CIRCLE ONE) Department Director Mayor City Council
Detail: (i.e. address, location, parcel number, tax id, etc.):
Human Services General Fund contract with Pediatric Interim Care Center for care of
drug-exposed infants, providing 24 hour medical monitoring and nursing care to withdraw
infants from dug-dependency and stabilize them for home care. This CSA is a two-year
contract for 2615-2016, with the second year of funding contingent upon availability of
funds and successful agency performance.
*Passed as part of the 2015 City of Kent budget
As of: 08/27/14
KENO"
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CONSULTANT SERVICES AGREEMENT
between the City of Kent and
Pediatric Interim Care Center
THIS AGREEMENT is made between the City of Kent, a Washington municipal corporation
(hereinafter the "City"), and Pediatric Interim Care Center organized under the laws of the State
of Washington, located and doing business at 328 41h Avenue South, Kent, WA 98032
(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 administer the Interim Care for Drug-Exposed Infants program,
providing 24-hour medical monitoring and nursing care to withdraw infants from
drug-dependency and stabilize them for home care. The following exhibits are
attached and incorporated by the reference as if fully set forth herein; Exhibit A,
Scope and Schedule of work; Exhibit B, Insurance Certificate; and Exhibit C,
Debarment Certification.
Consultant further represents that the services furnished under this Agreement will be
performed in accordance with generally accepted professional practices within the Puget Sound
region 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. Consultant
shall complete the work described in Section I by December 31, 2016.
III. COMPENSATION.
A. The City shall pay the Consultant, based on time and materials, an amount not to
exceed $20,000 ($10,000 per year), 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 amendment to
this agreement. The Consultant agrees that the hourly or flat rate charged by it for
its services 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 A.
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
CONSULTANT SERVICES AGREEMENT - 1
(Over$10,000)
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. By their execution of this
Agreement, and in accordance with Ch. 51.08 RCW, the parties make the following
representations:
A. 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.
B. The Consultant maintains and pays for its own place of business from which
Consultant's services under this Agreement will be performed.
C. The Consultant has an established and independent business that is eligible
for a business deduction for federal income tax purposes that existed before
the City retained Consultant's services, or the Consultant is engaged in an
independently established trade, occupation, profession, or business of the
same nature as that involved under this Agreement.
D. The Consultant is responsible for filing as they become due all necessary tax
documents with appropriate federal and state agencies, including the Internal
Revenue Service and the state Department of Revenue.
E. The Consultant has registered its business and established an account with
the state Department of Revenue and other state agencies as may be
required by Consultant's business, and has obtained a Unified Business
Identifier (UBI) number from the State of Washington.
F. The Consultant maintains a set of books dedicated to the expenses and
earnings of its business.
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 j
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.
CONSULTANT SERVICES AGREEMENT - 2
(Over$10,000)
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.
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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.
In the event Consultant refuses tender of defense in any suit or any claim, if that tender
was made pursuant to this indemnification clause, and if that refusal is subsequently determined
by a court having jurisdiction (or other agreed tribunal) to have been a wrongful refusal on the
Consultant's part, then Consultant shall pay all the City's costs for defense, including all
reasonable expert witness fees and reasonable attorneys' fees, plus the City's legal costs and
fees incurred because there was a wrongful refusal on the Consultant's part.
The provisions of this section shall survive the expiration or termination of this
Agreement.
VIII. INSURANCE. The Consultant shall procure and maintain for the duration of the
Agreement, insurance of the types and in the amounts described in Exhibit B 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.
CONSULTANT SERVICES AGREEMENT - 3
(Over$10,000)
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, including all appeals, 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.
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
CONSULTANT SERVICES AGREEMENT - 4
(Over$10,000)
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.
I. City Business License Required. Prior to commencing the tasks described in Section
I, Contractor agrees to provide proof of a current city of Kent business license pursuant to
Chapter 5.01 of the Kent City Code.
J. Counterparts. This Agreement may be executed in any number of counterparts,
each of which shall constitute an original, and all of which will together constitute this one
Agreement.
IN WITNESS, the parties below execute this Agreement, which shall become
effective on the last date entered below.
CONSULTANT: CITY OF KENT:
By: By:
(signature) _ (signature)
Print Name: rev\n2h Plit N . Suzette Cooke
Its EX ec u+']V t� i -e r Its Mayor
(title)
DATE:/ cpq r) J a 0I 5 DATE:
{
NOTICES TO BE SENT TO: NOTICES TO BE SENT TO:
CONSULTANT: CITY OF KENT:
Barbara Drennen, Executive Director Merina Hanson
Pediatric Interim Care Center City of Kent
328 4th Avenue South 220 Fourth Avenue South
Kent, WA 98032 Kent, WA 98032
253-852-5253 (telephone) (253) 856-5070 (telephone)
253-852-5728 (facsimile) (253) 856-6070 (facsimile)
APPROVED AS TP FORM:
Kent Law Department
[in this field,you may enter the electronic riilepath vmere the contraa has been saved]
CONSULTANT SERVICES AGREEMENT - 5
(Over$10,000)
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.
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 Ifill the five requirements referenced above.
KBy: 6�1 " n
For: Tf e-d i2--rim n�er�m 1�0.re� CPw Y
Title: E�-y t-U-JHUe- rec+or
Date: o Ul,s---
EEO COMPLIANCE DOCUMENTS - 1
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CITY OF KENT
ADMINISTRATIVE POLICY
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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.
By:
For:
Title:
Date:
II
EEO COMPLIANCE DOCUMENTS - 3
Exhibit A
KENT Scope and Schedule of Work
PARKS, RECREATION S 2015-2016 Consultant Services Agreement
COMMUNITY SERVICES
Agency: Pediatric Interim Care Center 2015 Funding: 10 000
Program: Interim Care of Drug-Exposed Infants 2016 Funding* 10 000
This funding 24-hour medical monitoring and nursing care to
will provide: withdraw infants from drug-dependency and stabilize Total: $20,000
them for home care.
Annual Program Outputs: Program Outcomes:
Unduplicated Kent Residents 1 Individuals and/or families improve health
Units of Care 24 Hours of Care 16 (physical/dental/mental).
Pursuant to Item I. of the Consultant Services Agreement (CSA) executed on January 1, 2015, Consultant
shall provide the approximate number of City of Kent clients with the following services each year of the
CSA:
Quarter Service Unit # of Units Cumulative
Total
lst Unduplicated City of Kent clients served 1 1
Units of Care 24 Hours of Care 4 4
2 nd Unduplicated City of Kent clients served 0 1
Units of Care 24 Hours of Care 4 8
3rd Unduplicated Cit of Kent clients served 0 1
Units of Care 24 Hours of Care 4 12
4th Unduplicated City of Kent clients served 0 1
Units of Care 24 Hours of Care 4 16
ANNUAL South King Council of Human Services Participation Yes/No Yes/No
The above services shall be provided by December 31, 2015 for year one of the two-year agreement and
December 31, 2016 for year two of the agreement.
Contract Administration
- The Consultant shall notify the City, in writing, within ten (10) days of any changes in program
personnel or board membership.
- The Consultant shall separately report the number of clients served who reside in the newly annexed
Panther Lake area as detailed in the provided maps.
- The Consultant shall provide the City with a current list of its board of directors, general or limited
partners, as applicable.
The Consultant will hold active membership with the South King Council of Human Services
- All records related to this CSA must be retained for three (3) years plus the current year.
I'
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Exhibit A (continued)
KENT Scope and Schedule of Work
2015-2016 Consultant Services Agreement
PARKS, RECREATION S
COMMUNITY SERVICES
Agency: Pediatric Interim Care Center 2015 Funding, 10 000
Program: Interim Care of Drug-Exposed Infants 2016 Funding: 10 000
This funding 24-hour medical monitoring and nursing care to
will provide: withdraw infants from drug-dependency and stabilize Total: $20,000
them for home care.
Reporting Requirements and Timeline
All data and required forms shall be submitted through SharelApp:
Service Unit Report - Data from this form will be used to track each program's progress toward meeting
the goals stipulated in the Scope of Work. It shall be submitted quarterly, no later than the 15th of the
month following the end of the quarter (i.e. April 15, July 15, Oct 15, Jan 15), along with the
Reimbursement Request.
Reimbursement Request -This form will be filled out on SharelApp and serve as the invoicing mechanism
for payment to your agency/program. It shall be submitted quarterly, no later than the 15th of the month
following the end of the quarter (i.e. April 15, July 15, Oct 15, ]an 15), unless otherwise specified.
Demographic Data Report -The agency shall collect and retain the data requested on this form from the
persons served through this contract. Data should be tracked in an ongoing manner and submitted annually
in SharelApp (by January 15).
Annual Outcome Data Report - Outcome data shall be submitted in SharelApp no later than the 15th
following the end of the second quarter (i.e. July 15). Data should demonstrate the program's progress
toward Outcomes specified in the Scope of Work.
Report Due Date
Service Unit Report and Reimbursement Request 15th day following each quarter
Final Reimbursement Request (4t Qtr) December 15t", 2015/December 15th, 2016
Demographic Data Report January 15th, 2016/January 15th, 2017
Annual Outcome Data Report January 15th, 2016/January 15", 2017
Signature
Please sign below to indicate acceptance of the Year 2015 and Year 2016 Performance Measures listed
above,
Barbara/pre en Executive Director Date
Mer a anson," uman Services Manager Date
EXHIBIT B
INSURANCE REQUIREMENTS FOR
HUMAN SERVICES GENERAL FUND AGREEMENTS
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 Liabilitv 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 1185. 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 11 85 or a substitute endorsement providing equivalent coverage.
2. Automobile Liability insurance covering all owned, non-owned, hired and
leased vehicles. Coverage shall be written on Insurance Services Office (ISO)
form CA 00 01 or a substitute form providing equivalent liability coverage. If
necessary, the policy shall be endorsed to provide contractual liability
coverage.
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. Automobile Liability insurance with a minimum combined single limit for
bodily injury and property damage of $1,000,000 per accident.
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C. Other Insurance Provisions
The insurance policies are to contain, or be endorsed to contain, the following
provisions for Automobile Liability and Commercial General Liability insurance:
�I
EXHIBIT B (Continued)
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 ANII.
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.
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.
pppa PEDIA-1 OP 10: PF
CERTIFICATE OF LIABILITY INSURANCE DATEIMM12014 Y)
07f08/2014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsements.
PRODUCER NAME: Tom Tom Taylor,Jr.,CPCU
Tayy NE]or-Thomason Ins. Brokers
3401 South 19th Street PHO ,253-284-7900 ac No! 253-284-7901
P.O. Box 7187 ADoss:tom ttib.net
Tacoma, WA 98417 -
Tom Taylor,Jr,CPCU INSURERS AFFORDING COVERAGE NAIL k
INSURER A:Phi lade) h is Insurance Company
INSURED Pediatric Interim Care Center INSURER B:James River Ins CO
Barbara Drennan
328 4th Ave S INSURER C;
Kent,WA 98032 INSURERD:
INSURER E:
INSURER P
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE 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 MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS.
INSR ADDL SUBS POLICYEFF POLICVEXP
LTR TYPE OFINSURANCE 11,11112111APOLICYNLJMSER DffYYY) (MMIDDIYVOJ LIMITS
B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
CLAIMS-MADE OCCUR X 0006299M 07/0112014 07/01/2015 PREMISES aoccurrence $ 50,000
X Professional MED EXP(Any on.person) $ exclude
PERSONAL&ADV INJURY $ 1,000,00
GEN'L AGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 3,000,00
X POLICY M JECT [7 LOC PRODUCTS-COMPIOPAGG $ Included
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
accident
A ANY AUTO PHPK1109M 07/01/2014 07/0112015 BODILY INJURY(Per Person) $ 1,000,00
AAULOOSSWNEO X AUTOS ULED 80DILY INJURV(Per accident) $
X HIREDAUTOS X NOIdOWNED PROPERTY DAMAGE $
AUTOS erawidenl
UMBRELLA LIAB H OCCUR EACH OCCURRENCE $
EXCESSLIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION I PER OTH-
AND EMPLOYERS'LIABILIW YIN STATUTE ER
�ICC-R/MEMEEREXCLNEE XECUTIVE ❑ N/A E.L.EACH ACCIDENT $
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $
Mus,descdbeunder
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS(VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached Ir more space Is required)
Liability deductible $5,000; Retro-active date 06/30/2002
Certificate Holder is named additional insured
CERTIFICATE HOLDER CANCELLATION
CITYKNT
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,. NOTICE WILL BE DELIVERED IN
City.Of Kent ACCORDANCE WITH THE POLICY PROVISIONS. III
Attn: Marina Hanson
220 4th Ave S AUTHORIZED REPRESENTATIVE q
Kent,.WA98032
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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VA S'TON INSURANCE COMPANY
Endorsement
Named Insured: Attached to and forming
a part of Policy No.: SM8 95061
Pediatric Interim Care Center Endorsement No.:
Effective Date of Endorsement: 07/01/13
ADDITIONAL INSURED ENDORSEMENT—BODILY INJURY/PROPERTY DAMAGE
LIABILITY(BLANKET)
This endorsement modifies insurance provided under the following:
Specified Medical Professions General Liability insurance Coverage Part
In consideration of the premium paid, it is hereby understood and agreed that the policy is amended
as tollows:
I, Section The Insured is amended by the addition of the following:
Whenever used in this Coverage Part, the unqualified word Insured shall also mean
Additional Insured.
2. Additional Insured means, whenever used in this endorsement, the following:
any person or organization to whom the Named Insured is obligated by valid vailten
contract to provide coverage as an additional insured to such person or organization but
only as respects liability for Bodily Injury or Property Damage caused by the negligence of
the Named Insured and only for Occurrences, Claims or coverage not otherwise excluded
in the policy.
3. Coverage provided to any Additional Insured as defined herein shall apply solely to an
Occurrence involving the products, goods, operations or premises covered by this
Coverage Part,
4. No coverage shall be afforded to the above Additional Insured for Bodily Injury or
Property Damage to any Employee or to any obligation of the Additional Insured to
indemnify another because Damages arising out of such injury,
5. Where no coverage shall apply herein for the Named Insured, no coverage or defense
shall be afforded to the above Additional Insured.
All other provisions of the policy shall apply and remain unchanged.
Authorized Representative
EIC 4671 08107
I
KE1dT Exhibit C
PARKS•RECREATION A
COMMUNItt SERVICES C City of Kent
Certification Regarding/ Debarment and Suspension
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Agency Name of Program(s)
Certification A: Certification Regarding Debarment, Suspension, and Other
Responsibility Matters - Primary Covered Transactions
1. The prospective primary participant certifies to the best of its knowledge and belief that
its principals;
a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from covered transactions by any Federal debarment or agency;
b) Have not within a three-year period preceding this proposal, been convicted of or had a
civil judgment rendered against them for commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State,
or local) transaction or contract under a public transaction; violation of Federal or State
antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification, or
destruction of records, making false statements, or receiving stolen property;
c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental
entity (Federal, State, or local) with commission of any of the offenses enumerated in
paragraph (1)(b) of this certification; and
d) Have not within a three-year period preceding this application/ proposal had one or more
public transactions (Federal, State, or local) terminated for cause or default.
2. Where the prospective primary participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this proposal.
Instructions for Certification (A)
1. By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2. The inability of a person to provide the certification required below will not necessarily
result in denial of participation in this covered transaction. The prospective participant
shall submit an explanation of why it cannot provide the certification set out below.
The certification or explanation will be considered in connection with the department
or agency's determination whether to enter into this transaction. However, failure of
the prospective primary participant to furnish a certification or an explanation shall
disqualify such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which reliance
was placed when the department or agency determined to enter into this transaction.
If it is later determined that the prospective primary participant knowingly rendered
an erroneous certification, in addition to other remedies available to the Federal
Government/City of Kent, the department or agency may terminate this transaction
for cause of default.
4. The prospective primary participant shall provide immediate written notice to the
department or agency to whom this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, lower tier
covered transaction, participant, person, primary covered transaction,
principal, proposal, and voluntarily excluded, as used in this clause, have the
1 of 3
meanings set out in the Definitions and Coverage sections of the rules implementing
Executive Order 12549. You may contact the department or agency to which this
proposal is being submitted for assistance in obtaining a copy of these regulations.
6. The prospective primary participant agrees by submitting this proposal that, should
the proposed covered transaction be entered into, it shall not knowingly enter into
any lower tier covered transaction with a person who is debarred, suspended,
declared ineligible, or voluntarily excluded from participation in this covered
transaction, unless authorized by the department or agency entering into this
transaction.
7. The prospective primary participant further agrees by submitting this proposal that it
will include the clause titled 'Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion - Lower Tier Covered Transaction," provided by
the department or agency entering into this covered transaction, without
modification, in all lower tier covered transactions and in all solicitations for lower tier
covered transactions.
8. A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that it is not debarred, suspended,
ineligible, or voluntarily excluded from the covered transaction, unless it knows that
the certification is erroneous. A participant may decide the method and frequency by
which it determines this eligibility of its principals. Each participant may, but is not
required to, check the Non-procurement List.
9. Nothing contained in the foregoing shall be construed to require establishment of a
system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
10. Except for transactions authorized under paragraph (6) of these instructions, if a
participant in a covered transaction
11. Knowingly enters into a lower tier covered transaction with a person who is
suspended, debarred, ineligible, or voluntarily excluded from participation in this
transaction, in addition to other remedies available to the Federal Government/City of
Kent, the department or agency may terminate this transaction for cause of default.
Certification B: Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion - Lower Tier Covered Transactions
1. The prospective lower tier participant certifies, by submission of this proposal, that
neither it nor its principals is presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from participation in this transaction by any
Federal department or agency.
2. Where the prospective lower tier participant is unable to certify to any of the statements
in this certification, such prospective participant shall attach an explanation to this
proposal.
Instructions for Certification (B)
1. By signing and submitting this proposal, the prospective lower tier participant is
providing the certification set out below.
2. The certification in this clause is a material representation of fact upon which reliance
was placed when this transaction was entered into. If it is later determined that the
prospective lower tier participant knowingly rendered an erroneous certification, in
addition to other remedies available to the Federal Government/City of Kent, the
department or agency with which this transaction originated may pursue available
2 of
remedies, including suspension and/or debarment.
3. The prospective lower tier participant shall provide immediate written notice to the
person to which this proposal is submitted if at any time the prospective lower tier
participant learns that its certification was erroneous when submitted or has become
erroneous by reason of changed circumstances.
4. The terms covered transaction, debarred, suspended, ineligible, lower tier
covered transaction, participant, .person, primary covered transaction,
principal, proposal, and voluntarily excluded, as used in this clause, have the
meanings set out in the Definitions and Coverage sections of rules implementing
Executive Order 12549. You may contact the person to which this proposal is
submitted for assistance in obtaining a copy of these regulations.
5. The prospective lower tier participant agrees by submitting this proposal that, should
the proposed covered transaction be entered into, it shall not knowingly enter into
any lower tier covered transaction with a person who is debarred, suspended,
declared ineligible, or voluntarily excluded from participation in this covered
transaction, unless authorized by the department or agency with which this trans-
action originated.
6. The prospective lower tier participant further agrees by submitting this proposal that
it will include this clause titled "Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion - Lower Tier Covered Transaction," without
modification, in all lower tier covered transactions and in all solicitations for lower tier
covered transactions.
7. A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that it is not debarred, suspended,
ineligible, or voluntarily excluded from the covered transaction, unless it knows that
the certification is erroneous. A participant may decide the method and frequency by
which it determines the eligibility of its principals. Each participant may, but is not
required to, check the Nonprocurement List.
8. Nothing contained in the foregoing shall be construed to require establishment of a
system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
9. Except for transactions authorized under paragraph (5) of these instructions, if a
participant in a lower covered transaction knowingly enters into a lower tier covered
transaction with a person who is suspended, debarred, ineligible, or voluntarily
excluded from participation in this transaction, in addition to other remedies available
to the Federal Government/City of Kent, the department or agency with which this
transaction originated may pursue available remedies including suspension and/or
debarment.
Executive Director (P 1r, ) Title Date
Signature of Execu Ile irector Title Date
(3.
Adopted from HUD Form-2992
09/04
3 of
REQUEST FOR T( SIGNATURE
®NT Please Fill in All Applicable Boxes
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Routing Information (ALL REQUESTS MUST FIRST BE ROUTED THROUGH THE LAW DEPARTMENT)
Originator: Christine Cain APPROVALS:
Date Sent: March 3, 2015 DATE OF COUNCIL APPROVAL:
Return Signed Document to: C.Cain DATE OF CHIEF ADMINISTRATIVE
OFFICER APPROVAL:
VENDOR NAME: Pediatric Interim Care DATE OF FINANCE DIRECTOR
Center APPROVAL:
Date Re uired: March 17, 2015
Phone (Originator):253-856-5063 BUDGETED: YES M NO ❑
FUND:
Brief Explanation of Document:
Human Services General Fund contract with Pediatric Interim Care Center for care of
drug-exposed infants, providing 24 hour medical monitoring and nursing care to
withdraw infants from dug-dependency and stabilize them for home care. This CSA is a
two year contract for 2015-2016, with the second year of funding contingent upon
availability of funds and successful agency performance.
*Passed as part of the 2015 City of Kent budget
All Contracts Must Be Routed Through The Law Department
(This area to be completed by the Law Department)
Received:
s
Approval of Law Dept.:
v E ;
Law Dept. Comments:
1
Date Forwarded to Mayor:
Shaded Areas To Be Completed By Administration Staff
Received:
Recommendations and Comments:
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Date Returned: ,P'b f �' t� dyy w,