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2 <br />BASIC PROVISIONS <br />Service Provider <br />Insurance Contact <br />Information <br />Hub International Northwest LLC <br />425-455-5000 <br />cindy.sams@hubinternational.com <br />State Retirement <br />Systems (must <br />answer both <br />questions) <br />Does Service Provider have 25 or more employees? <br /> <br />Answer: No <br /> <br />If Service Provider has less than 25 employees, did any Service Provider <br />Personnel who will work under this Professional Services Agreement retire <br />under a DRS retirement system? <br /> <br />Answer: No <br /> <br />“DRS retirement system” refers to any of the following Public Employers’ <br />Retirement System (PERS), School Employees’ Retirement System (SERS), <br />Teachers’ Retirement System (TRS), and Law Enforcement Officers and <br />Fire Fighters plan (LEOFF). <br /> <br />“Service Provider Personnel” includes Service Provider employees and <br />owners (such as shareholders, partners or members). If Service Provider is <br />a sole proprietor, then “Service Provider Personnel” refers to the sole <br />proprietor. <br />Willful Wage <br />Violation <br />Certification <br />By signing this Agreement, the Service Provider certifies that, within the five- <br />year period immediately preceding the date of Service Provider’s signature, <br />the Service Provider has not been determined by a final and binding citation <br />and notice of assessment issued by the Washington Department of Labor and <br />Industries or through a civil judgment entered by a court of limited or general <br />jurisdiction to have willfully violated, as defined in RCW 49.48.082, any <br />provision of chapter 49.46, 49.48, or 49.52 RCW. This certification covers any <br />entity, however organized, that is substantially identical to Service Provider. <br />Submission of an untrue certification by Service Provider is a material breach <br />and cause for Agreement termination. <br /> <br />END OF BASIC PROVISIONS <br />