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HomeMy WebLinkAboutPK07-020 - Original - Community Health Centers of King County - Primary Medical & Dental Care - 01/01/2007 Records Management KENT Document WASHINGTON 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 Mary Simmons, City Clerks Office. M-M VV�u V)rr 4-1r,0c,1�1�. Vendor Name: �� ° t V Vendor Number: JD Edwards Number Contract Number: PK07 —020 This is assigned by Mary Simmons Description: 7y, nA i I r wt ( C4 Jl , f r, ►' Y a a4 Detail: o'lA,1'YL61,V1 oycs �1GrAl fund 1 °10 C'on'f?'atC-�- -. � Project Name: N Contract Effective Date: " U� Termination Date: 12 3 Contract Renewal Notice (Days): j r 30 D40S Number of days required notice for termination or renewal or amendment Contract Manager. maivid IS" Department: L&S RV Y06W Wo c es Abstract: nno ( VI , s S Pubhc\RecordsManagement\forms\ContractCover\ADCL7832 07/02 KEN T W.S....TO. CONSULTANT SERVICES AGREEMENT between the City of Kent and Community Health Centers of King County THIS AGREEMENT is made between the City of Kent, a Washington municipal corporation (hereinafter the "City"), and Community Health Centers of King County organized under the laws of the State of Washington, located and doing business at 403 E. Meeker St #300, Kent, WA, 98030 (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 will provide primary dental and/or medical care to low-income and uninsured residents of Kent, Auburn, Covington,Des Moines, Federal Way, Renton, SeaTac and Tukwila. This is an agreement entered into between the Con l Su tart and the City of Kent, acting or, behalf of itself, and Auburn, Coving-toil,Des J Ul Moines, Federal Way, Renton, SeaTac and Tukwila pursuant to a Memorandum of Understanding, dated February 4, 2003, between the participating cities for planning, finding and implementation of a joint human services application and funding program. The following exhibits are attached and incorporated by this reference as if fully set forth herein: Exhibit A, Scope and Schedule of Work, Exhibit B, Billing Voucher and Service Report; Exhibit C, Kent First and Final Outcome Report, Exhibit D, Demographic Report; Exhibit E, Insurance Cetertificate; and Exhibit F, Debarment Certification. 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 term of this Agreement shall run from January 1,2007, through December 31, 2008. However, due to the delay in execution of this Agreement,the parties agree that all actions consistent with the authority of this Agreement and prior to the date of the Agreement's execution are hereby ratified and affirmed, and the terms of this Agreement shall be deemed to have applied The parties agree that Consultant shall complete the work described in Section I by December 31, 2008. This Agreement, however, is contingent upon the availability of funds to be allocated through the City's budget process. During the term of this Agreement should the City determine that funds to support Consultant's services are no longer available, the City shall provide Consultant seven(7) days advance written notice of summary termination. III. COMPENSATION. A. The City shall pay the Consultant, based on time and materials, an amount not to exceed $446,232 ($223,116 per year) for the services described in this Agreement. This is the maximum CONSULTANT SERVICES AGREEMENT- 1 (Over$10,000) i 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 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 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. VL 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 CONSULTANT SERVICES AGREEMENT-2 (over$10,000) 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. 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 E 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, CONSULTANT SERVICES AGREEMENT-3 (Over$70,000) 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 shalt 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 OF KENT: By: By: (signature (signature) Print Name: 7ho ��S �Gon-mtdz Print e: SuAtte Cooke Its l �2 Its a v (Title) ule) DATE: �/IS�b DATE: �` h NOTICES TO BE SENT TO: NOTICES TO BE SENT TO: CONSULTANT: CITY OF KENT: Thomas Trompeter, Executive Director Katherin Johnson, Human Services Manager Community Health Centers of King County City of Kent 403 E. Meeker St- Suite 300 220 Fourth Avenue South Kent, WA 98030 Kent, WA 98032 CONSULTANT SERVICES AGREEMENT-4 (Over$10,000) (206) 329-1011 (telephone) (206) 461-3726 (facsimile) (253) 856-5070 (telephone) 253 856-5073 (facsimile) APPAZOVED AS TO FORM: e Law De i nt P Human Sery ices�General Fund\General Fund 2007-2008 Contract\CHCKC CSA 2007-2008\ 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 Cityof Kent administrative policy number 1.2. P Y 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 1, 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 ay of 2001 By: For: lC L -,t tie, �l� & Title: Date: ��j 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 organizat;on 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 12 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 2007 CONSULTANT SERVICES AGREEMENT COMMUNITY HEALTH CENTERS OF KING COUNTY Primary Dental Care This program provides comprehensive primary dental care to low income and uninsured families and individuals. Services are provided to uninsured and underinsured clients on a sliding-fee scale according to family size and income The cities of Kent, Covington, Renton, SeaTac and Tukwila provide funding for this program to secure services for residents of the Cities of Kent, Covington, Renton, SeaTac and Tukwila. This funding will provide: Outputs Unduplicated Kent clients 66 Dental visits to Kent clients 200 Unduplicated Covington clients 7 Dental visits to Covington clients 22 Unduplicated Renton clients 63 Dental visits to Renton clients 190 Unduplicated SeaTac clients 17 Dental visits to SeaTac clients 50 Unduplicated Tukwila clients 8 Dental visits to Tukwila clients 25 Membership & Participation in the South King Council of Human Services Outcome(s) Individual's self-reliance is supported by Improved oral health of children and adults living in South King County communities Contract Administration The Consultant will notify the City, in writing, within (10) days of any changes in program personnel or board membership The Consultant shall provide the City with a current list of its board of directors, general or limited partners, as applicable. All records related to this contract must be retained for three years plus the current year. EXHIBIT A SCOPE OF WORK (CONTINUED) Budget City of Kent Budget: Personnel $20,000 Nonpersonnel $ -0- City of Covington Budget: Personnel $2,160 Nonpersonnel $ -0- City of Renton Budget: Personnel $19,000 Nonpersonnel $ -0- City of SeaTac Budget: Personnel $5,000 Nonpersonnel $ -0- City of Tukwila Budget: Personnel $2,500 Nonpersonnel $ -0- Total: $48,660 2007 Reimbursement: City of Kent $20,000 City of Covington $ 2,160 City of Renton $19,000 City of SeaTac $ 5,000 City of Tukwila $ 2,500 Total $48,660 Reporting Requirements and Timeline The agency will be reimbursed on a quarterly basis, upon submittal of appropriate documentation Such documentation will include the following (as applicable) Billing Voucher & Service Report (Exhibit B), Outcome Based Evaluation Report (Exhibit C), and Client Demographic Data (Exhibit D) These items must be submitted on forms provided by the City by the 10th of following month for the previous quarter of service The reporting timeline is as follows Billing Voucher&Service Report(Exhibit B) 10T"day following each quarter Final Billing Voucher(4th Qtr Exhibit B) December 14, 2007 Outcome Based Evaluation Report(Exhibit C) July 31, 2007/January 31, 2008 Client Demographic Data (Exhibit D) January 31,2008 EXHIBIT A SCOPE OF WORK (CONTINUED) COMMUNITY HEALTH CENTERS OF KING COUNTY 2007 CONSULTANT SERVICES AGREEMENT Primary Dental Pursuant to Item 1 of the Consultant Services Agreement executed on January 1, 2007, Community Health Centers of King County shall provide the approximate number of clients from the Cities of Kent, Covington, Renton, SeaTac and Tukwila with the following services: QUARTER 15 2" 3` 4 Annual City of Kent Performance Measures Total 1 Number of Unduplicated Kent Clients 16 16 17 17 66 2 Dental Visits to Kent Clients 50 50 50 50 200 QUARTER 1$ 2" 3rd 4th Annual City of Covington Performance Measures- Total 1 Number of Unduplicated Covington Clients 1 2 2 2 7 2 Dental Visits to Covington Clients 5 5 6 6 22 QUARTER 1$ 2" 3 rd 4 th Annual City of Renton Performance Measures* Total 1 Number of Unduplicated Renton Clients 15 16 16 16 63 2 Dental Visits to Renton Clients 47 47 48 48 190 QUARTER 1s 2" 3 rd 4th Annual City of SeaTac Performance Measures: Total 1 Number of Unduplicated SeaTac Clients 4 4 4 5 17 2. Dental Visits to SeaTac Clients 12 12 13 13 50 QUARTER 1g 2" 3` 4th Annual City of Tukwila Performance Measures Total 1 Number of Unduplicated Tukwila Clients 2 2 2 2 8 2. Dental Visits to Tukwila Clients 6 6 6 7 25 The above services shall be provided by December 31, 2007. Please sign to indi to acce tance of the Year 2007 Performance Measures listed above lr Thomas Trompeter,Executi ire r Date Katherin Johnson, HunAn Mrvv ana r Date x/ 17, 677 EXHIBIT A SCOPE AND SCHEDULE OF WORK 2008 CONSULTANT SERVICES AGREEMENT COMMUNITY HEALTH CENTERS OF KING COUNTY Primary Dental Care This program provides comprehensive primary dental care to low income and uninsured families and individuals Services are provided to uninsured and underinsured clients on a sliding-fee scale according to family size and income The cities of Kent, Covington, Renton, SeaTac and Tukwila provide funding for this program to secure services for residents of the Cities of Kent, Covington, Renton, SeaTac and Tukwila This funding will provide: Outputs Unduplicated Kent clients 66 Dental visits to Kent clients 200 Unduplicated Covington clients 7 Dental visits to Covington clients 22 Unduplicated Renton clients 63 Dental visits to Renton clients 190 Unduplicated SeaTac clients 17 Dental visits to SeaTac clients 50 Unduplicated Tukwila clients 8 Dental visits to Tukwila clients 25 Membership & Participation in the South King Council of Human Services Outcomes) Individual's self-reliance is supported by improved oral health of children and adults living in South King County communities Contract Administration The Consultant will notify the City, in writing, within (10) days of any changes in program personnel or board membership. The Consultant shall provide the City with a current list of its board of directors, general or limited partners, as applicable. All records related to this contract must be retained for three years plus the current year. EXHIBIT A SCOPE OF WORK (CONTINUED) Budge City of Kent Budget: Personnel $20,000 Nonpersonnel $ -0- City of Covington Budget: Personnel $2,160 Nonpersonnel $ -0- City of Renton Budget: Personnel $19,000 Nonpersonnel $ -0- City of SeaTac Budget: Personnel $5,000 Nonpersonnel $ -0- City of Tukwila Budget: Personnel $2,500 Nonpersonnel $ -0- Total: $48,660 2008 Reimbursement: City of Kent $20,000 City of Covington $ 29160 City of Renton $199000 City of SeaTac $ 5,000 City of Tukwila $ 2,500 Total $48,660 Reporting Requirements and Timeline The agency will be reimbursed on a quarterly basis, upon submittal of appropriate documentation Such documentation will include the following (as applicable) Billing Voucher & Service Report (Exhibit B), Outcome Based Evaluation Report (Exhibit C), and Client Demographic Data (Exhibit D) These items must be submitted on forms provided by the City by the I& of following month for the previous quarter of service The reporting timeline is as follows Billing Voucher&Service Report(Exhibit B) 10T"day following each quarter Final Billing Voucher(4th Qtr Exhibit B) December 15, 2008 Outcome Based Evaluation Report(Exhibit C) July 31, 2008/January 30, 2009 Client Demographic Data (Exhibit D) January 30, 2009 EXHIBIT A SCOPE OF WORK (CONTINUED) COMMUNITY HEALTH CENTERS OF KING COUNTY 2008 CONSULTANT SERVICES AGREEMENT Primary Dental Pursuant to Item 1 of the Consultant Services Agreement executed on January 1, 2007, Community Health Centers of King County shall provide the approximate number of clients from the Cities of Kent, Covington, Renton, SeaTac and Tukwila with the following services: QUARTER 1$ 2" 3` 4 th Annual City of Kent Performance Measures Total 1 Number of Unduplicated Kent Clients 16 16 17 17 66 2 Dentai Visits to Kent Clients 50 50 50 50 200 QUARTER 1S 2" 3rcl 4th Annual City of Covington Performance Measures Total 1 Number of Unduplicated Covington Clients 1 2 2 2 7 2 Dental Visits to Covington Clients 5 5 6 6 22 QUARTER 15 2" 3` 4thAnnual City of Renton Performance Measures Total 1 Number of Unduplicated Renton Clients 15 16 16 16 63 2 Dental Visits to Renton Clients 47 47 48 48 190 QUARTER 15 2 nd 3rcl 4th Annual City of SeaTac Performance Measures Total 1 Number of Unduplicated SeaTac Clients 4 4 4 5 17 2 Dental Visits to SeaTac Clients 12 12 13 13 50 QUARTER 15 2" 3rd 4th Annual City of Tukwila Performance Measures Total 1 Number of Unduplicated Tukwila Clients 2 2 2 2 8 2 Dental Visits to Tukwila Clients 6 6 6 7 25 The above services shall be provided by December 31, 2008. Please sign to indicate acceptance of the Year 2008 Performance Measures listed above. �r Thomas Tromp ter xe tive Director Dat Katherin Johnsi5n, Human 4sices Ma ger Date EXHIBIT A SCOPE AND SCHEDULE OF WORK 2007 CONSULTANT SERVICES AGREEMENT COMMUNITY HEALTH CENTERS OF KING COUNTY Primary Medical Care This program provides comprehensive primary medical care to low-income and uninsured families and individuals living in the Cities of Kent, Auburn, Covington, Des Moines, Federal Way, Renton, SeaTac, and Tukwila. This funding will provide: Outputs Unduplicated Kent clients 182 Unduplicated Auburn clients 27 Medical visits to Kent clients 456 Medical visits to Auburn clients 68 Unduplicated Covington clients 11 Unduplicated Des Moines clients 8 Medical visas to Covington clients 27 Medical visits to Des Moines clients 20 Unduplicated Federal Way clients 101 Unduplicated Renton clients 96 Medical visits to Federal Way clients 253 Medical visits to Renton clients 240 Unduplicated SeaTac clients 123 Unduplicated Tukwila clients 10 Medical visits to SeaTac clients 307 Medical visits to Tukwila clients 24 Membership & Participation in the South King Council of Human Services Outcome(s) Individual's self-reliance is supported by increased access to primary care and preventive health services within South King County community Contract Administration The Consultant will notify the City, in writing, within (10) days of any changes in program personnel or board membership The Consultant shall provide the City with a current list of its board of directors, general or limited partners, as applicable. All records related to this contract must be retained for three years plus the current year EXHIBIT A SCOPE OF WORK (CONTINUED) Budget City of Kent Budget: Personnel $57,000 Nonpersonnel $ -0- City of Auburn Budget: Personnel $8,536 Nonpersonnel $ -0- City of Covington Budget: Personnel $3,420 Nonpersonnel $ -0- City of Des Moines Budget: Personnel $2,500 Nonpersonnel $ -0- City of Federal Way Budget: Personnel $31,600 Nonpersonnel $ -0- City of Renton Budget: Personnel $30,000 Nonpersonnel $ -0- City of SeaTac Budget: Personnel $38,400 Nonpersonnel $ -0- City of Tukwila Budget: Personnel $3,000 Nonpersonnel $ -0- Total: $174,456 Reporting Requirements and Timeline The agency will be reimbursed on a quarterly basis, upon submittal of appropriate documentation Such documentation will include the following (as applicable) Billing Voucher & Service Report (Exhibit B), Outcome Based Evaluation Report (Exhibit C), and Client Demographic Data (Exhibit D). These items must be submitted on forms provided by the City by the 10`h of following month for the previous quarter of service The reporting timeline is as follows Billing Voucher& Service Report(Exhibit B) 10T"day following each quarter Final Billing Voucher(4'h Qtr Exhibit B) December 14, 2007 Outcome Based Evaluation Report(Exhibit C) July 31, 20071January 31, 2008 Client Demographic Data (Exhibit D) January 31,2008 EXHIBIT A SCOPE OF WORK (CONTINUED) COMMUNITY HEALTH CENTERS OF KING COUNTY 2007 CONSULTANT SERVICES AGREEMENT Primary Medical Pursuant to Item 1 of the Consultant Services Agreement executed on January 1, 2007, Community Health Centers of King County shall provide the approximate number of clients from the Cities of Kent, Auburn, Covington, Des Moines, Federal Way, Renton, SeaTac and Tukwila with the following services: QUARTER 1$ 2nd 3rd 40 Annual City of Kent Performance Measures: Total 1 Number of l Indijiplicated Kent Clients 45 45 46 46 182 2 Medical Visits to Kent Clients 114 114 114 114 456 QUARTER 1s 2" 3rd 4th Annual City of Auburn Performance Measures Total 1 Number of Unduplicated Auburn Clients 6 7 7 7 27 2 Medical Visits to Auburn Clients 17 17 17 17 68 QUARTER Ist2" 3 rd4 Annual City of Covington Performance Measures Total 1 Number of Unduplicated Covington Clients 2 3 3 3 11 2 Medical Visits to Covington Clients 6 7 7 7 27 QUARTER 15 2" 3rd Annual City of Des Moines Performance Measures: Total 1 Number of Unduplicated Des Moines Clients 2 2 2 2 8 2 Medical Visits to Des Moines Clients 5 5 5 5 20 QUARTER 1g 2" 3` 4th Annual City of Federal Way Performance Measures- Total 1 Number of Unduplicated Federal Way Clients 25 25 25 26 101 2 Medical Visits to Federal Way Clients 63 63 63 64 253 QUARTER 15 2" 3rd 4th Annual City of Renton Performance Measures Total 1 Number of Unduplicated Renton Clients 24 24 24 24 96 2 Medical Visits to Renton Clients 60 60 60 60 240 (Continued on Next Page) EXHIBIT A SCOPE OF WORK (CONTINUED) COMMUNITY HEALTH CENTERS OF KING COUNTY — 2007 CONSULTANT SERVICES AGREEMENT Primary Medical QUARTER 1$ 2" 3rd 4 Annual City of SeaTac Performance Measures: Total 1 Number of Unduplicated SeaTac Clients 30 31 31 31 123 2 Medical Visits to SeaTac Clients 76 77 77 77 307 QUARTER 1S 2" 3 rd 4 Annual City of Tukwila Performance Measures: Total 1 Number of Unduplicated Tukwila Clients 2 2 3 3 10 2. Medical Visits to Tukwila Clients 6 6 6 6 24 The above services (including preceding page) shall be provided by December 31, 2007 2007 Reimbursement: City of Kent $57,000 City of Auburn $ 8,536 City of Covington $ 3,420 City of Des Moines $ 2,500 City of Federal Way $31,600 City of Renton $30,000 City of SeaTac $38,400 City of Tukwila $ 3,000 Total $174,456 Please sign to indicate acceptance of the Year 2007 Performance Measures listed above. Thomas Trompe er, utive Director Date Katherin Johnso , Hu n e ce Ma er Date ' EXHIBIT A SCOPE AND SCHEDULE OF WORK 2008 CONSULTANT SERVICES AGREEMENT COMMUNITY HEALTH CENTERS OF KING COUNTY Primary Medical Care This program provides comprehensive primary medical care to low-income and uninsured families and individuals living in the Cities of Kent, Auburn, Covington, Des Moines, Federal Way, Renton, SeaTac, and Tukwila. This funding will provide: Outputs Unduplicated Kent clients 182 Unduplicated Auburn clients 27 Medical visits to Kent clients 456 Medical visits to Auburn clients 68 Unduplicated Covington clients 11 Unduplicated Des Moines clients 8 Medical visits to Covington clients 27 Medical visits to Des Moines clients 20 Unduplicated Federal Way clients 101 Unduplicated Renton clients 96 Medical visits to Federal Way clients 253 Medical visits to Renton clients 240 Unduplicated SeaTac clients 123 Unduplicated Tukwila clients 10 Medical visits to SeaTac clients 307 Medical visits to Tukwila clients 24 Membership & Participation in the South Kin Council of Human Seances � 9 Outcome(s) Individual's self-reliance is supported by increased access to primary care and preventive health services within South King County community. Contract Administration The Consultant will notify the City, in writing, within (10) days of any changes in program personnel or board membership The Consultant shall provide the City with a current list of its board of directors, general or limited partners, as applicable. All records related to this contract must be retained for three years plus the current year. EXHIBIT A SCOPE OF WORK (CONTINUED) Budget City of Kent Budget: Personnel $57,000 Nonpersonnel $ -0- City of Auburn Budget: Personnel $8,536 Nonpersonnel $ -0- City of Covington Budget: Personnel $3,420 Nonpersonnel $ -0- City of Des Moines Budget: Personnel $2,500 Nonpersonnel $ -0- City of Federal Way Budget: Personnel $31,600 Nonpersonnel $ -0- City of Renton Budget: Personnel $30,000 Nonpersonnel $ -0- City of SeaTac Budget: Personnel $38,400 Nonpersonnel $ -0- City of Tukwila Budget: Personnel $3,000 Nonpersonnel $ -0- Total: $174,456 Reporting Requirements and Timeline The agency will be reimbursed on a quarterly basis, upon submittal of appropriate documentation Such documentation will include the following (as applicable) Billing Voucher & Service Report (Exhibit B); Outcome Based Evaluation Report (Exhibit C), and Client Demographic Data (Exhibit D) These items must be submitted on forms provided by the City by the 10'h of following month for the previous quarter of service The reporting timeline is as follows. Billing Voucher& Service Report(Exhibit B) 10T"day following each quarter Final Billing Voucher(41h Qtr Exhibit B) December 15, 2008 Outcome Based Evaluation Report(Exhibit C) July 31,2008IJanuary 30, 2009 Client Demographic Data (Exhibit D) January 30, 2009 EXHIBIT A SCOPE OF WORK (CONTINUED) COMMUNITY HEALTH CENTERS OF KING COUNTY 2008 CONSULTANT SERVICES AGREEMENT Primary Medical Pursuant to Item 1 of the Consultant Services Agreement executed on January 1, 2007, Community Health Centers of King County shall provide the approximate number of clients from the Cities of Kent, Auburn, Covington, Des Moines, Federal Way, Renton, SeaTac and Tukwila with the following services: QUARTER 1` 2nd 3rd 4 Annual City of Kent Performance Measures- Total 1 Number of Undupim ted Kent Clients 45 45 46 46 182 2 Medical Visits to Kent Clients 114 114 114 114 456 QUARTER 1° 2nd 3rcl Annual City of Auburn Performance Measures Total 1 Number of Unduplicated Auburn Clients 6 7 7 7 27 2. Medical Visits to Auburn Clients 17 17 17 17 68 QUARTER 1$ 2" 3 rd 4th Annual City of Covington Performance Measures Total 1 Number of Unduplicated Covington Clients 2 3 3 3 11 2 Medical Visits to Covington Clients 6 7 7 7 27 QUARTER 1$ 2" 3 rd 4 Annual City of Des Moines Performance Measures: Total 1 Number of Unduplicated Des Moines Clients 2 2 2 2 8 2. Medical Visits to Des Moines Clients 5 5 5 5 20 QUARTER 1$ 2" 3 4 Annual City of Federal Way Performance Measures Total 1 Number of Unduplicated Federal Way Clients 25 25 25 26 101 2 Medical Visits to Federal Way Clients 63 63 63 64 253 QUARTER 1$ 2" 3 rd 4 th Annual City of Renton Performance Measures Total 1 Number of Unduplicated Renton Clients 24 24 24 24 96 2 Medical Visits to Renton Clients 60 60 60 60 240 (Continued on Next Page) EXHIBIT A SCOPE OF WORK (CONTINUED) COMMUNITY HEALTH CENTERS OF KING COUNTY— 2008 CONSULTANT SERVICES AGREEMENT Primary Medical QUARTER 1` 2 nd 3rd 4th Annual City of SeaTac Performance Measures Total 1 Number of Unduplicated SeaTac Clients 30 31 31 31 123 2 Medical Visits to SeaTac Clients 76 77 77 77 307 QUARTER I St 2 nd 3 rd 4th Annual City of Tukwila Performance Measures- Total 1 Number of Unduplicated Tukwila Clients 2 2 3 3 10 2 Medical Visits to Tukwila Clients 6 6 6 6 24 The above services (including preceding page) shall be provided by December 31, 2008. 2008 Reimbursement: City of Kent $57,000 City of Auburn $ 8,536 City of Covington $ 3,420 City of Des Moines $ 2,500 City of Federal Way $31,600 City of Renton $30,000 City of SeaTac $38,400 City of Tukwila $ 3,000 Total $174,456 Please sign to indicate acceptance of the Year 2008 Performance Measures listed above. 7 Thomas Trompeter, xebftive Director Date xr/, / 707 Katherin Johns oh, H n Skgjo6s Man er Date Exhibit B General Fund KENT 2007 Billing Voucher WASHINGTON and Service Report PARKS, RECREATION S. COMMUNITY SERVICES To: Merina Hanson Agency: Community Health Centers of K.C. Housing & Human Services Parks, Recreation & Community Services Program Contact: 220 4th Ave, South, Kent, WA 98032 Telephone: mnanson(a ci kent wa us E=mail: Phone: 253 856-5077 Reporting Period Program Amount Requested Primary Dental $ 48,660 BUDGET SUMMARY FOR DEPARTMENT-USE ONLY Total Contract Amount $ VENDOR_NUMBER#33917 Current Request $ ACCOUNT CODE 1000-6370-64150-4701 Amount Remaining $ 2007 SERVICE UNITS Note: Unduplicated client counts must be reported both quarterly and year-to-date. C4,61"Kent Performanes,Meaeii�ids '� «�,.Planned Service Unitis U� , ,`lNew_C1fY WE TataltC ty�=-�; _T�otalservibi Funded Serce Funded Units to Date Units Service Units (ALL Funding 1st 2nd 31 4th3'- This Quarter- To Date - Sources) Number of Unduplicated Kent Clients 16 16 17 17 Dental visits to Kent clients 50 50 50 50 City of Covington Perforrnance- Planned Service Unit Newc -= assort �w �T taC e ; MeaSUreS: Funded Service Funded Units to Daten- 1s1 2nd 3rd 4th Units Service Units (ALL Funding` This Quarter To Date Sources) Number of Unduplicated Covington Clients 1 2 2 2 Dental visits to Covington clients 5 5 6 6 Cityof Renton Perfioimance Measures:'' "Planned 5ervi6e'Units �"f'� New'dty=- -T6tat-CW',' Total SII Funded Service Funded Units to Date, Ist 2nd 3rd ` 41h- Units Service Units (ALL Funding` This Quarter To Date Sources) Number of Unduplicated Renton clients 15 15 16 16 Dental visits to Renton clients 47 47 48 48 Exhibit B General Fund KENT 2007 Billing Voucher WASHINGTON and Service Report PARKS, RECREATION s (page 2 of 2) COMMUNITY SERVICES Community Health Centers of King County — Primary Dental 'Cif y of SeaTac Per#o�mance Measures: Planned�Service Units �1e�c�fy' ��"� T'otat otai'Service Funded Service Funded Units to Date 1st 2nd 3rd 4th Units Service Units (ALL Funding This Quarter-, To Date Sources) Number of Unduplicated SeaTac clients 4 4 4 5 Dental visits to Covington clients 1 12 12 1 13 13 ' Cttk"d Pik vi i� rfairt a e� '` . _ �e I i rtaifT�11c0,tlriit : ,rte �i y . total s `�I aarSern Measures: Funded Sernce Funded Units to Date v - - ,is .. ..� II1 its to—,,.,,i i...t {ALL Funding sat 2nd _ bra 4v1 .ncl r,w Units This Quarter To Date Sources) Number of Unduplicated Tukwila clients 2 2 2 2 Dental visits to Kent clients 6 6 6 7 Please provide a narrative explanation in the event that the agency did not meet the quarterly performance measure: Authorized Signature Date FOR DEPARTMENT USE ONLY AUTHORIZED FOR PAYMENT 6i z BY: DATE: Exhibit B General Fund �WKNT 2007 Billing Voucher WASHINGTON and Service Report PARKS, RECREATION & COMMUNITY SERVICES To: Merina Hanson Agency: Community Health Centers of K.C. Housing & Human Services Parks, Recreation & Community Services Program Contact: 220 4th Ave. South, Kent, WA 98032 Telephone: mhanson(fti.kent.wa us E-mail: Phone: 253 856-5077 Reporting Period Program Amount Requested Primary Medical Is BUDGET SUMMARY FOR DEPARTM ENT_USE ONLY °.:-, Total Contract Amount $ 174,456 'VENDOR NUM ER#3391'7 ` Current Request $ ACCOUNT CODE-1 000-6370-641504700 Amount Remaining $ 2007 SERVICE UNITS Note: Unduplicated client counts must be reported both quarterly and year-to-date. City o tfetit PerfoFixt �fiae leasure '£` Pla'nne Service Units ` Newcity TotalliCit Funded Service Funded Units to Date 1 1st Znd 3rd 4th Units Service Units (ALL Funding - This Quarter To Date Sources) Number of Unduplicated Kent Clients 45 45 46 46 Medical visits to Kent clients 114 114 114 114 i of Auburn,PIir"6t*",c 'Mea`ird' Planned Service Units-` - New ci" � rotat`eit ty�` y}` 'Total Seniice Funded Service Funded Units to Date 1st Znd 3rd 4th Units Service Units (ALL Funding This Quarter To Date Sources) Number of Unduplicated Auburn Clients 6 7 7 7 Medical visits to Auburn clients 17 17 17 17 City of Covington Performance Planned Service Units New 6iij aF,°" Totai'Cify ,,!, Totai serv',ce Measures: Funded Service Funded Units to Date 1st 2nd 3rd 4th Units Service Units (ALL Funding This Quarter 1 To Date Sources) Number of Unduplicated Covington Clients 2 3 3 3 Medical visits to Covington clients 6 7 7 7 Exhibit B General Fund Z 140 0 0 2007 Billing Voucher WASHINGTON and Service Report PARKS, RECREATION S (page 2 of 2) COMMUNITY SERVICES Community Health Centers of King County — Primary Medical City of Des Moines Performance Planned Service Units view City Total City o alSe?vf Measures: Funded Service Funded Units to Date ist 2nd 3rd 4th Units Service Units (ALL Funding This Quarter To Date Sources) Number of Unduplicated Des Moines Clients 2 2 2 2 Medical visits to Des Moines clients 5 5 5 5 Cit �afFederal Way Fd Fbrriiatics `�Plenned`5er ice Unlff' m New-chy �T661bi���=_ Totatservi�e Funded Service Funded Units to Date easures: - Ist 2nd 3rd 4th Units Service Units (ALL Funding - This Quarter ° To Date Sources) Number of Unduplicated Federal Way clients 25 25 25 26 Medical visits to Federal Way clients 63 63 63 64 City Of Renton Performance-Measures: Planned Service Units ` ' New CRY' Total city Total Service Funded Service Funded Units to Date Ist, 2nd 3rd 4th Units Service Units (ALL Funding - Tnis Quarter To Date Sources) Number of Unduplicated Renton clients 24 24 24 24 Medical visits to Renton clients 60 60 60 60 City of SeaTac Performance Measures:' _'-` � Planned Service Units New City Total city Total Service Funded Service Funded Units to Date tst 2nd r 3rd 4th _ Units e n , Service Units (ALLFunding,p This Quarter To bate Sources) _ Number of Unduplicated SeaTac clients 30 31 31 31 Medical visits to SeaTac clients 76 77 77 77 City of'Tukwila Performance` Planned Service Units -NewCiry " Totat'c;ty �'Tot aiser„ice Measures: Funded Service Funded Units to Date Ast," 2nd 3rd 4th Units Service Units (ALL Funding - This Quarter To Date Sources) Number of Unduplicated Tukwila clients 2 2 3 3 Medical visits to Tukwila clients 6 6 6 6 *Please attach a narrative explanation in the event that agency did not meet quarterly performance measures. Authorized Signature Date FOR DEPARTMENT USE ONLY AUTHORIZED FOR PAYMENT BY: DATE: H ti ti Q' c o O Na. W M °' W O F- �o D ' O ' ca ai > o ccu EL o C Z 0 dLu N Q N ` Y a rn E a m 2 — E o E v ca +r a w y d a s w o cz LL vi N N C O O a O m c 4- co o Q a`) .n E D o o Z p ULL m CL aL m E ` O (D _ O r c W E ° o w n Z C O Q) W N ° o c G1 v o �a W W CL t U C L O rL 3 Q Z+ N N +�+ E N a V U rC C cu IO Q) Q � � F— ono O N N 0 W M M 0. LU p r C O 0M U as c CD a z IMo LL CL > O Z v °' LV -a a Y ,o E Q a) 12 a o E c ccu E Y r Q d cd s cu L O I^�, (D C O O C Q Q Nccu Y I L C O a y x E Eo LL Z g U� 0) N a 'a o. o +�+ U O W E V O z w a z oU c C O N N OZ. W w Q 0 W= �; a� C N < E 0) m L. O co in Y (0 .0 .0 O U 0 a) a U >. N a) 4.0 � � N Q � CC �"� N E w m N N O C 0 Q (n (1) 0 C O O NN o W M " W O = ai -- O as � ai > o > LL o a H V W r. Q cu Y Q E Q ar m — o E v +� a w d Q s r .. cd o cc L a� c o o c °- o N a) � C O ca a x � Lo E `o Z p ULL rn —� cu CL F— m L m E i O N O C C WE V G � =50 : i5 A Z C O a) 70 o > o � o V p F-a W W U oz` � In a O ) w � i c .. rn W s W F N L � E c6 i z E w 0 O z E E rf 0 R a � o a O +' (D E Q cn in � (D � oqk W � LU ■ � 2 § O $ O a (1) J 5 3 Q G co Z 7 @ > � \ ` Z k 2 § ƒ \ Z = LLJ 2 E ) CL E E 2 ■ < LL k / 0 W . \ 0 � \ E E o U LL Z 0 CL \ / t 0 m x 0 • 0 % { \ E k c a >1 ( ( g o c o / o E E E 2 2 )( & \ @ % § /_ �\ )� 2 .0 § U _/ 7 § » k \ 2 2 G § E , ) u 0 2 @ _ -.000'0."• Agency, KENT Exhibit D Program WASHINGTON 2007 Demographic Report Date PARKS, RECREATION S COMMUNITY SERVICES Unduplicated Number of Clients Served; Agency/Program Unduplicated New Individuals this Year Client Residence** 11 7 Algona Auburn Black Diamond Buren Covington Des Moines Enumclaw Federal Way Kent Maple Valle Milton Normandy Park Pacific Renton SeaTac Seattle Tukwila Unincorporated King Count Unknown TOTAL Household Income Level 4. 30%of Median or Below 50%of Median or Below 80%of Median or Below Above 80% of Median Unknown TOTAL Gender - Male Female TOTAL Age 0-4 years 5- 12 years 13- 17 years 18- 34 years 35- 54 years 55-74 years 75+years Unknown TOTAL Ethnicity Asian/Pacific Islander Black/Afncan American Hispanic/Latino(a) Native American/Alaskan Native White/Caucasian Other Unknown TOTAL Female Headed Household Disabling Condition Limited English Speaking " Unduplicated means count each client only once per calendar year "List of all clients served in client residence category and Kent clients only in rest of the categories Agency KENT Exhibit D Program: W,="'"a"O" 2008 Demographic Report Date PARKS. RECREATION S COMMUNITY SERVICES Unduplicated Number of Clients Served* Agency/Program —Unduplicated (New) Individuals this Year Client Residence** ` Algona Auburn Black Diamond Burien Covington Des Moines Enumclaw Federal Way Kent Maple Valle Milton Normandy Park Pacific Renton SeaTac Seattle Tukwila Unincorporated King Count Unknown TOTAL Household Income Level 30%of Median or Below 50%of Median or Below 80%of Median or Below Above 80% of Median Unknown TOTAL Gender Male Female TOTAL Age 0-4 years 5- 12 years 13- 17 years 18-34 years 35-54 years 55-74 years 75+years Unknown TOTAL Ethnicity Asian/Pacific Islander Black/African American Hispanic/Latino(a) Native American/Alaskan Native White/Caucasian Other Unknown TOTAL Female Headed Household Disabling Condition Limited English Speaking " Unduplicated means count each client only once per calendar year. **List of all clients served in client residence category and Kent clients only in rest of the categories ATTACHMENT E INSURANCE REQUIREMENTS FOR CONSULTANT 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. A. Minimum Scope of Insurance Consultant 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 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. 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 Consultant 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. EXHIBIT E (Continued ) 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. 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. 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 ANII. 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. YYY ACORDI, CERTIF1 1ITE OF LIABILITY INSURANCE CSR CH I DATE(MMIDDIYO61 COMM-1 05 25 PRODUCER "— THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFE14S NO RIGHTS UPON THE CERTIFICATE Sprague Tsr_ael Giles HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 1501 Fourth Avenue, Suit G 2000 ALTER THE COVEF.AGE AFFORDED BY THE POLICIES BELOW. Seattle WA 99101-1637 one: 206-623-7035 Fa:a ? )15-1582-4993 INSURERS AFFORDIdGCOVERAGE NAIC# INSURERA___ Amarimn eaonnmy Inearanm Co INSURER R American Staten inecranoa Co Communit�yy 8ealhIG ( Brt'ers et al INSURERC` _ 403 E. Mi kgr 30( INSURERD Kent WA 99031- INSURERS ----- - --- ---- COVERAGES _~! 1HF POI Ir IF6 Of'INN[IRAN('I-I ISTED BE)CiN H1 IF EEI N ISSUED TO 1HE INSURED NAMED ABOVF FOR THE POLICY PER OD INDICATED NO1 WITHSTANDING ANY RFOUIRFMFN1 I FRM OR CONDITION 11F AI 1 ONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CF;TIFICATE MAY BE ISSUED OR MAY I'rR THIN,FBI=INSURANCF ATFORDIO R' F POI ICIES DESCRIBED HEREIN IS SUBJECT 1 P A'L THE TERMS,FXCI L:IONS AND CONDITIONS OF SUCH POI In IFS AG(7RFGAl F t IMITs SHOWN MA"Y A. I EE N REDUCED BY PAID Cl AIMS __ _ CYIEFFECTm 1RSCfCY LIMITS LTR NS_R_ _ TYPE OF INSURANCE POLICY NUMBER DATE MMlDDIYY DATE IA IDWYY _ �� GENFRAI I IAF111 ITY _ EACH OCCURRENCE $2,000,000 A I X X r;<NIMFRrIN G n n C1 eNrRAtIIHI 28P46630710 06/01/06 06"01/v7 Q;R fsEGEss a} $2,000 000 CI AIMS MADE I X�00 L I MED EXP(Any ens person) 1 10,000 X STOP GAP PERSONAL A ADV INJURY $2 000,000- GENERALAr,GREGATE s4,000,000 rFN'I AGGREGATE I IMIT APPI IFr 1 FI PRODUCTS-COMP/OP AGO $ 41000,000 _X PDI ICY I PRO � L) A0110MORII F I IARII ITY COMBINED SINGLE LIMIT $ 1 000 000 A $ X nN AUTO 02CE13652710 06/01/06 061'01/07 IEeetcden) r r At 1 OWNED At ITOS BODILY INJURY SCHFOIII FD A11T03 (Per person) $ 1{ ILRFDAlif08 BODILY INJURY $ X NON OVVNFUAUTOS (Per accident) X 1$250 Comp PROPERTY DAMAGE $ X I$500 Coll (Par accident) GARAGE LIARII I TY AUTOONLY EAACCIDENT It ANV AIJIO EAACC $ — OTHER THAN AUTOONLY AGG $ EXC"SIUMRRM I LIARII ITY EACH OCCURRENCE _ $1 000 000 13 X X OCCUR + ltIAIMsNxi 01SU38227110 06/01/06 06/01/07 AGGREGATE $1,000,000 DmUCTIRIL �. - $ --^- -- X RETENTION _ $1010'111 _—� $ WORKERS COMPENSATION AND AR' LIMITS ER CMPI OYFRS'I IARII ITY - —'— — — EI EACH ACCIDENT $ AN} PRD..^RIETOWPARlN(-PIEYFCI�^,'/F - - OI I IPFRIMFMPFR TXCI UDF07 �I�� HOG DISEASE-EAEMPLOYE $ Des,denrrino urldol -- �'�-- — ---- SPFC-tAl PROVISIONS below EL DISEASE-POLICY LIMB $ Omr" _ -.— HOUSING & K r q `,ERVIO S OESCRIPTIOnt t7f OPFRATlON31LOCATION3Jf1' If LES1ERCLUSIDNS ADDED BY ENDORSEMENT I SPECIAL PROVISIONF The City of. Kent, TtS rr: H,',t nd and/or appointed officials, its employees and agents RInq County Taff, nfluned as additional insureds with :respects to fund i nq_ CERTIFICATE HOLDER_ _-� CANCELLATION KENT004 SHOULD ANY OF THE J,19OVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIOD DATE THEREOF,THE IIISUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN City of Rent NOTICE TO THR CERTO'ICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 80 SHALL Planning Depariv lUt IMPOSE NO OBLIGATII IN OR LIABILITY OF ANY KIND UPON ThE INSURER,ITS AGENTS OR Kather-in Johnm al 220 4th Ave 8 UT1i ENTATNES, Kent WA 98032-F,111!i ATHO PRESEvT ACORD 93(2001108) —� ©ACORD CORPORATION 1981 POLICY NUMBER: 1 071 34775 COMMERCIAL GENERAL LIABILITY THIS ENDORSENIf: h,11 CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL . 'INSURED -- DESIGNATED PERSON OR ORGANIZATION This endorsement modifies a mrance provided under the following: COMMERCIAL GENE hA, _(ABILITY COVERAGE PART. SCHEDULE Name of Person or Orgar Ia r1 ion: City of Kent City of Kent, its elected andlct appointed officials, Planning Departmen its employees and agents&King County 220 4`h Avenue Sout 7 Kent, WA 98032-5 c� (if no entry appears abov , >+onnation required to complete this endorsemen.will be shown in the Declarations as applicable to this ender rent) WHO IS AN INSURED(S:, )on II) is amended to include as an insured the p;:rson or organization shown in the Schedule as an insured o,ii only with respect to liability arising out of your operations or premises owned by or rented to you CG 20 26 11 85 Copyright, Insurance Services Office, Inc., 1981 Page 1 of 1 0 KENT Exhibit F PARKS RECREATION S COMMUNITY SERVICES City of Kent Certification Regarding Debarment and Suspension 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, o,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 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 1 of 3 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 Exclu- sion - 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 Ce rtiflcation 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 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 her 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 transaction originated 2of3 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 Exclu- sion - 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 S. 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 Primary Contractor/Sub-Contractor(Print) Title Date I limns 4� C � U�F Signature of PrimA44meTirtractor/Sub- r Title Date (3, Adopted from HUD Form-2992 09/04 3of3