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Insurance - Xylem Dewatering Solutions Inc - 2012-02-27AFRO® °AT02a 2012"'"' CERTIFICATE OF LIABILITY INSURANCE TYPE OF INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER ADO Risk services Northeast, Inc. New York NV Office 199 Water Street New York NY 10038 -3551 USA CONTACT NAME: LIMITS (Nd NNo.Eat): (866) 283 -7122 " NO.: (847) 953 -5390 F-MAL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL# INSURED Xylem Dewatering Solutions, Inc. d /b /a Godwin Pumps of America, a wholly owned subsidiary of xylem Inc. 84 Floodgate Road Bridgeport NJ 08014 USA INSURERA: ACE American Insurance Company 22667 INSURER e: $1,000,000 INSURERC: PREMISES Es occurrence) INSURER D: MED EXP(Any one pawn) INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570045362384 RFVICIf1N NI IMRFR- _d I'$ c v 9 0 M THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits Shown are as requested LTR TYPE OF INSURANCE INSR WD POLICY NUMBER UM POLICY LIMITS GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE %OCCUR XSLG SIR applies per policy terns & condl ions EACH OCCURRENCE $1,000,000 PREMISES Es occurrence) $1,000,000 MED EXP(Any one pawn) EXCluded PERSONAL B ADV INJURY $1,000,000 GENERALAGGREGATE $2,000,000 GEN'LAGGREMJ1E1MITAPPLIES PER: PRODUCTS - COMPIOP AGG $1,000,000 % POLICY PRO LOC 0 SIR $1,000,000 A AUTOMOBILE LIABILITY ISA H0869395A 10 31 2 110 31 2012 COMBINED SINGLE LIMIT Ea a. $1,000,000 BODILY INJURY( Per person) X ANY AUTO 0 ALL OWNED SCHEDULED AUTOS AUTOS z 14 BODILY INJURY IPeraatlanQ PROPERTYDAMCGE Peraaklanf HIREDAUTOS NON -OWNED AUTOS �0 UMBRELLA LIAB OCCUR EACH OCCURRENCE e U EXCESS LAB CLAIMS -MADE AGGREGATE CEO IRETENT ION A A WORKERS COMPENSATION AND EMPLOYERB'LIABILRY PNYPROPRIETORIPARTNERIEXEMI'VE YIN OFFICERIMEMBER EXCLUDEDR NIA WLRC 6773627 WC All other States SCFC46773639 10 31 11 10/31/2011 10 31 20 10/31 /2012 WC STATU- OTH- X TORYLIMITS E E.L. EACH ACCIDENT $1,000,000 (Mantletgry In NX) Hyee,tleactlbe antler WC WI Only E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMB _$1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addlflonal Remarks Schedule, if more apace Is required) Costa Mesa Sanitary District is included as Additional Insured as required by written contract, but limited to the operations of the Insured under said contract, with respect to the General Liability and Automobile Liability policies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. aaayyy7 Costa Mesa sanitary DistPiCt ` lJ 628 W. 19th street Costa Mesa CA 92627 USA AUTHORIZED REPRESENTATNE ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: XSL G25534463 ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CONTRACT ENDT. 3121 Named Insured Endorsement Number Xylem Inc. 21 Policy 5ymbol Policy Number Policy Period Effective Date of Endorsement XSL G25534463 10/31/2011 to 10/31/2012 Issued By (Name of Insurance Company) ACr? American Insurance Company THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. This endorsement modifies all insurance provided under the following: EXCESS COMMERCIAL GENERAL LIABILITY POLICY The following is added to Section 11.2 -Who Is An Insured. e. Any person or organization that you are required to include as an additional insured under this policy because of a written contract that: 11 Is in effect during this policy period; and 2) Was executed prior to the "occurrence" of the "bodily injury" or "property damage ": and 3) Qualifies as an "insured contract' as defined in this policy. Such person or organization is an additional insured only for: 4) Coverage under Section I — Coverages, Coverage A. Bodily Injury and Property Damage Liability; and 5) Liability arising out of "your work" or "your product" for that additional insured; and 6) For the period of time required by the written contract and in no event beyond the expiration of this policy. In the event that the Limits of Insurance provided by this policy exceed the Limits of Insurance required by the written contract; 7) The Insurance provided by this endorsement shall be limited to the Limits of Insurance required by the written contract; and 8) This endorsement shall not increase the Limits of Insurance stated in the Declarations under Item 3. Limits of Insurance pertaining to the coverage provided herein, Any coverage provided by this endorsement to an additional insured shall be excess over any other valid and collectible insurance available to the additional insured whether primary, excess, contingent or on any other basis unless the written contract specifically requires that this insurance apply on a primary or non- contributory basis. In accordance with the terms and conditions of the policy and as more fully explained in the policy, as soon as practicable, each additional insured must give us prompt notice of any "occurrence' which may result in a claim, forward all legal papers to us, cooperate in the defense of any actions, and otherwise comply with all of the policy's leans and conditions. " "^ Authorized Agent XS -21234 (11108) Printed in U.S.A. Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1