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CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission
to the City Clerk's Office. All portions are to be completed.
If you have questions, please contact the City Clerk's Office at 253-856 5725.
Vendor Name: Green fiver Community College
Vendor Number:
Jib Edwards Number
Contract Number: �G 1 1 — T11
This is assigned by City Cleric's Office.
Project Name: Small Business Assistance Center
Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment 2 Contract
El Other:
Contract Effective Date: Termination bate: 12/31/17
Contract Renewal Notice (Days):
Number of days required notice for termination or renewal or amendment
Contract Manager: Kurt Hanson Department: ikon & Comm
Development
ContractAmount: 23,100.00
Approval Authority: ❑ Director Z Mayor ❑ CityCouncil Meeting mate
•
KENT
W A 9 M 1 N O T O N
CONSULTANT SERVICES AGREEMENT
between the City of Kent and
Green River Community College
Small Business Assistance Center
THIS AGREEMENT is made between the City of Kent, a Washington municipal
corporation (hereinafter the "City"), and Green River Community College Small Business
Assistance Center organized under the laws of the State of Washington, located and doing
business at 417 Ramsey Way, Suite 112, Kent, WA 98032, (253) 856-9595 (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:
As described in attached Exhibit A, Scope of Work
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, 2017.
III. COMPENSATION.
A. The City shall pay the Consultant, based on time and materials, an amount
not to exceed Twenty-Three Thousand One Hundred and 00/100 Dollars
($23,100.00), 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
2017 CONSULTANT SERVICES AGREEMENT 1
Green River Community College
Small Business Assistance Center
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. 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 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
2017 CONSULTANT SERVICES AGREEMENT 2
Green River Community College
Small Business Assistance Center
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 duty to defend, indemnify, and hold the City harmless, and Consultant's
liability accruing from that obligation 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 CONSULTANTS 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.
2017 CONSULTANT SERVICES AGREEMENT 3
Green River Community College
Small Business Assistance Center
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 Consultant acknowledges that the City is a public agency subject to the Public
Records Act codified in Chapter 42.56 of the Revised Code of Washington. As such, the
Consultant agrees to cooperate fully with the City in satisfying the City's duties and
obligations under the Public Records Act. 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
2017 CONSULTANT SERVICES AGREEMENT 4
Green River Community College
Small Business Assistance Center
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 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. Public Records Act. The Consultant acknowledges that the City is a public
agency subject to the Public Records Act codified in Chapter 42.56 of the Revised Code of
Washington and documents, notes, emails, and other records prepared or gathered by the
Consultant in its performance of this Agreement may be subject to public review and
disclosure, even if those records are not produced to or possessed by the City of Kent. As
such, the Consultant agrees to cooperate fully with the City in satisfying the City's duties
and obligations under the Public Records Act.
J. 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.
2017 CONSULTANT SERVICES AGREEMENT 5
Green River Community College
Small Business Assistance Center
K. Counterparts and Signatures by Fax or Email. 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. Further, upon executing this
Agreement, either party may deliver the signature page to the other by fax or email and
that signature shall have the same force and effect as if the Agreement bearing the
original signature was received in person.
(Remainder of page left intentionally blank)
2017 CONSULTANT SERVICES AGREEMENT 6
Green River Community College
Small Business Assistance Center
IN WITNESS, the parties below execute this Agreement, which shall
become effective on the last date entered below. All acts consistent with the
authority of this Agreement and prior to its effective date are ratified and
affirmed, and the terms of the Agreement shall be deemed to have applied.
CONSULTANT: CITY OF KENT:
By: By:
(signature) (signature)
Print Name: Leslie Moore Pri�j uze�tteCo�oke
. M NaJ
Its: Dean for Branch Campuses, it : M or
1-1
Date: Date:
NOTICES TO BE SENT TO: NOTICES TO BE SENT TO:
CONSULTANT$* CITY OF KENT:
Leslie Moore, Dean Kurt Hansen, Deputy Director
Green River Community College City of Kent
417 Ramsey Way, Suite 112 220 Fourth Avenue South
Kent, WA 98032 Kent, WA 98032
(253) 288-3375 (telephone) (253) 856-5706 (telephone)
APPRO D AS TO FORM;
K t L ,a'D e pa`rf men
P:\ADM IN\CONTRACTS\Green River\2017 SMAC\Agreement - Green River SBAC.docx
2017 CONSULTANT SERVICES AGREEMENT 7
Green River Community College
Small Business Assistance Center
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 fulfill the five requirements referenced above.
By:_ 4h A�±�-�
For: C " uue&-e
Title:
Date: �� I
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.
By:
For: f P�fiIGY� �
Title:
Date:
EEO COMPLIANCE DOCUMENTS 3
EXHIBIT A
Scone of Work
In 2017 the Green River Community College SBAC will continue to focus on fewer
clients with higher impacts per the city's request. Small Business billable hours
are calculated at $135 per hour. For a $23,100 grant, Kent will receive 171 hours
of direct client services. These services will target small businesses and will be
calculated by on-on-one technical assistance, advisor prep time, workshops and
meet-ups.
Client shall perform direct client services as requested to small businesses and
work on Project Feast for the City in accordance with the following described plans
and/or specifications;
• Business plan development
• Business location analysis
• Marketing and sales
• Small Business management
• Sources of capital
Time allocated for participation in the Food Innovation Network, run by Global 2
Local and advising small businesses in the food and restaurant industry will be up
to 72 hours. Attendance at Food Innovation Network meetings will be tracked and
reported.
Counseling sessions shall be available at no cost to the client.
The consultant shall provide quarterly reports to the City and an in-person
meeting to discuss services provided and outcomes.
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.
As all clients are self-selecting, this is the best SBAC estimation of impacts over a
12-month period based on previous years of experience. Actual results are based
on a number of factors, not all of which are under the control of the SBAC.
Confidentiality is a chief concern in reporting on SBAC activities. Reporting forms
will identify clients by number only and not by company name or owner.
EXHIBIT A 1
EXHIBIT B
INSURANCE-REQUIREMENTS FOR
CONSULTANT SERVICES AGREEMENTS
Insurance
The Consultant 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 Consultant, their agents,
representatives, employees or subcontractors.
Minimum Scope of Insurance
Consultant shall obtain insurance of the types described below:
1. 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.
Commercial General Liability insurance shall be written on ISO occurrence
form CG 00 01. The City shall be named as an Additional Insured under
the Consultant'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.
Minimum Amounts of Insurance
Consultant shall maintain the following insurance limits:
1. Automobile Liability insurance with a minimum combined single limit for
bodily injury and property damage of $1,000,000 per accident.
2. Commercial General Liability insurance shall be written with limits no less
than $1,000,000 each occurrence, $2,000,000 general aggregate.
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:
1. The Consultant'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 Consultant's insurance and shall not contribute with it.
EXHIBIT A 2
2. The Consultant'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 Consultant
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 Consultant'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
Consultant 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 Consultant before
commencement of the work.
F. Subcontractors
Consultant 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 Consultant.
EXHIBIT A 3
CERTIFICATE OF LIABILITY INSURANCE Issue Date 811412017
ISSUED BY: THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
State of Washington AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
Department of Enterprise Services CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE
Office of Risk Management AFFORDED BY THE STATE OF WASHINGTON SELF INSURANCE
PO BOX 41466 LIABILITY PROGRAM.
Olympia WA 98504-1466
COVERAGE AFFORDED BY
State of Washington Self Insurance Liability Program
INSURED: THE STATE OF WASHINGTON, INCLUDING ALL ITS AGENCIES AND
DEPARTMENTS,IS SELF-INSURED FOR TORT LIABILITY CLAIMS. ALL
State of Washington CLAIMS MUST BE FILED WITH THE STATE OFFICE OF RISK
Green River College MANAGEMENT FOR PROCESSING IN ACCORD WITH STATUTORY
ATTN: Stephanie Cheng-LaBoyne REQUIREMENTS.
12401 SE 320th Street
Auburn, WA 98092
COVERAGES
THIS IS TO CERTIFY COVERAGE DESCRIBED BELOW IS PROVIDED TO THE INSURED NAMED ABOVE FOR THE PERIOD INDICATED.
NOTWITHSTANDING ANY RECUP"ENT, TERM OR CONDITION OF CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE COVERAGE AFFORDED BY THE SELF-INSURANCE LIABILITY PROGRAM IS SUBJECT
TO ALL THE TERMS EXCLUSIONS,AND CONDITIONS OF SUCH PROGRAM.
POLICY EFFECTIVE EXPIRATION
TYPE OF COVERAGE NUMBER DATE DATE LIMITS
GENERAL LIABILITY Self-Insured Continuous Continuous BODILY INJURY,PROPERTY $5.000.000
®GENERAL LIABILITY DAMAGE&PERSONAL INJURY
® OCCURRENCE COVERAGE COMBINED EACH OCCURRENCE
AUTOMOBILE LIABILITY BODILY INJURY&PROPERTY $5,000,D00
❑ANY AUTO DAMAGE COMBINED EACH
®ALL OWNED AUTOS ACCIDENT
❑SCHEDULED AUTOS
❑HIRED AUTOS
❑NON-OWNED AUTOS
WORKERS COMPENSATION AND L&I Continuous Continuous WC—STATUTORY
EMPLOYERS LIABILITY 62WEGE1229 6130117 awls EL-$1,000,000—per Acddentl$1,000,000Disease
per Pollcyl$1,000,000 Disease per Employee
OTHER
DESCRIPTION OF OPERATIONSILOCAIICNSNEHICLES/SPECIAL ITEMS: Coverage applies as respects tort liability Claims against
the State of Washington as covered by the Tort Claims Act (RCW 4.92 at seq.) The Certificate Holder is named as
additional Insured,but only as respects the negligence of the State of Washington.
CERTIFICATE HOLDER: CANCELLATION
CITY OF KENT,WASHINGTON SHOULD THE SELF INSURANCE LIABILITY PROGRAM BE CANCELLED, THE
STATE OF WASHINGTON WILL ENDEAVOR TO MAIL !N DAYS WRITTEN
400 WEST GOWE NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE
KENT,WA 98032 TO MAIL SUCH NOTICE SHALL NOT IMPOSE ANY OBLIGATION OR LIABILITY
UPON THE STATE OF WASHINGTON, ITS OFFICIALS, EMPLOYEES,AGENTS
OR REMESENTATIVES.
AU7nSfams.
IZED REPRES::a'a)j
IVE:
CERTIFICATE NUMBER CRT 18-105
J State Riskr
Campbell, Melynda (DES)
From: noreply@formstack.com
Serer Monday,August 14,2017 11:09 AM
To: OFM Cl;Erickson, Paul(WaTech)
Subject: DES-Cert Ins Request Form -Green River College
Self Insurance Form - Certificate of Liability Insurance
CERTIFICATE OF LIABILITY INSURANCE REQUEST FORM
Sent:Aug 14,2017 11:08 AM
Form record 1D:344407866
Copy and paste the string below into the Excel file
CRT Green 12401 Auburn, City of 400 Kent,
SE Cheng- schenc_ Tanya
?.- River WA Stephenie Kent West WA tkosen rr. ent
??? Coll 9$092 LaBoynelabovneki greenriver.eduWashington Gowe 98032Kosen
Street
Your Agency Green River College
Agency Address 12401 SE 320th Street
Auburn,WA 98092
Your Name Stephenie Cheng-LaBoyne
Your Email schenc-laboyne(cygreenriver.e(lu
Your Phone (253)288-3353
Outside Entity City of Kent,Washington
"ATTN" Name Tanya Kosen
Certificate Holder tk0sgn(rt!kentwa. v
Email
Certificate Holder 400 West Gowe
Address Kent,WA 98032
Reason for Certificate Agreement between the Green River College Small Business Assistance Center
and the City of Kent
s
REQUEST FOR MAYOR'S SIGNATURE
K IZZTENT Please Fill in All Applicable Boxes
W.5Hl.0,U.
Originator: Julie Pulliam Phone (Originator): 5702
Date Sent: 8/25/17 Date of Council Approval:
Return Date of Approval from Finance:
Signed Document to: Julie Pulliam (Only required on contracts $10,000 &over or on any Grant
Agreements) Port of Seattle Grant Funding
Date Required: As soon as signed Date of Approval from Risk Manager:
Green River Community College Budgeted: YES 0 NO []
Budget Fund: 10004115.64190.1221
This is the yearly contract with Green River< ci ' College's Small Business
Assistance Center.
Agreement will end 12/31/17 and not exceed $23,100.00
A$QoWnM Mst Be Routed Through The Law Department
Ln rL7-
(This area to be completed by the Law Department)
Received: A1JG Z8 20P
Law Dep d s
T�ff�T UW b 0T.
Law Dept. Comments: &1( tojU) 61n4,,jt&CV))U eAj(t6V
pta, Num �Iliidj Pt4,k MWA,
Date Forwarded to Mayor.,
F, 11,77
Shaded Areas To Be Completed By Administration Staff
Received: 7"Wi 3
("hy of Ken. ,
Recommendations and Comments: office Of th e
Date Returned:
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