Insurance - Xylem Inc. - 2015-10-131 1 do
"✓ CERTIFICATE OF LIABILITY INSURANCE
OATE(MMIDDNYYY)
IIM3R015
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(les) 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
Aon Risk Services Northeast, Inc.
New York NV Office
CONTACT
NAME:
(AIC NNo.Exq: (866) 263-7122 jaC No : (800) 363-0105
E-MAIL
ADDRESS:
199 Water Street
New York NV 10038-3551 USA
RECEIVED
INSURER(S) AFFORDING COVERAGE NAIC #
INSURED f�
2015
INSURER A: ACE American Insurance Company 22667
Xylem water Solutions USA. Inc. OCT 19
Flygt Products
11161 Harrel Street COSTA MESA SANNANr D)SIBICi
INSURER e: ACE Fire Underwriters Insurance Co. 20702
INSURER C:
Mira Loma CA 91752 USA
INSURER D:
USA '(%
INSURER E:
SIR applies per policy terns
INSURER F:
COVERAGES CERTIFICATE NUMBER: blUUb981823U REVISION NUMBER'
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested
NSIR
LTR
TYPE OF INSURANCE
INSD
MD
POLICY NUMBER
O
MMIDDIgg
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
District
AUTHORIZED REPRESENTATIVE
XSLG
MD
EACH OCCURRENCE $1,000,000
Costa
CLAIMS -MADE ❑X OCCUR
USA '(%
SIR applies per policy terns
& condl
ions
DAMAGET $1,600,000
PREMISES Ea occurrence
MED EXP (Any one person) EXCI uded
PERSONAL &ADV INJURY $1,000,000
GENT AGGREGATE LIMIT APPLIES PER
GENERALAGGREGATE $10,000,000
X POLICY ❑PRO- ❑LOC
ECT
PRODUCTS-COMPIOPAGG $6,000,000
OTHER
SIR $1,000,000
A
AUTOMOBILE LIABILITY
ISA H0886066A
10/31/201510/31/2016
COMBINED SINGLE LIMIT $1,000,000
Ea accident
BODILY INJURY( Per person)
X ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS NON -OWNED
AUTOS
BODILY INJURY (Per accident)
PROPERTY DAMAGE
Per accident
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE
EXCESS LIAR
H
CLAIMS -MADE
AGGREGATE
DED RETENTION
A
WORKERS COMPENSATION AND
EMPLOYERS'LIABILITY YIN
IWLRC48592387
WC All Dt'Er States
10/31/2015
10/31/2016
�. PER DTH-
STATUTE ER
E.L. EACH ACCIDENT $1,()00,000
B
ANY PROPRIETOR I PARTNER I EXECUTIVE
OFFICERIMEMBER EXCLUDED i N
NIA
SCFC48592399
10/31/2015
10/31/2016
E.L. DISEASE -EA EMPLOYEE $1,000,000
(Mandatory in NH)
WC WI Only
It describe under
DESCRIPTION OF OPERATIONS below
EL DISEASE -POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached fmom space is required)
RE: Job Name: Lift Station Maintenance project. Costa Mesa Sanitary District, its officers, agents and employees are
included as Additional insured in accordance with the policy provisions of the General Liability policy.
CERTIFICATE HOLDER
CANCELLATION
91988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
`m
M
m
W
Co
0
0
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
Costa
Mesa Sanitary
District
AUTHORIZED REPRESENTATIVE
628 W.
19th Street
Costa
Mesa CA 92627
USA '(%
a/
91988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
`m
M
m
W
Co
0
0
ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CONTRACT
Named Insured
Endorsement Number
Xylem Inc.
2
Policy Symbol
Policy Number
Policy Period
Effective Date of Endorsement
XSL
627400401
10/31/2015 to 10/31/2016
Issued By (Name of Insurance Company)
ACE American Insurance Company
Insert the policy number. The remainder of the Information Is to be completed only when this endorsement is Issued subsequent to the preparation of the policy.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies 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:
1) 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.
Any such person or organization is an additional insured only for "bodily injury" and "property
damage" resulting from:
a. 'your work" that you do for that additional insured pursuant to such contract; or
b. "your product" distributed or sold to that additional insured pursuant to such contract; and
such person is only an additional insured for "occurrences" taking place during the period of time
required by such contract or until the end of the policy period, whichever is sooner.
However:
1) The insurance afforded to such additional insured only applies to the extent permitted by law; and
ii) If coverage provided to the additional insured is required by a contract or agreement, the insurance
afforded to such additional insured will not be broader than that which you are required by the
contract or agreement to provide for such additional Insured.
In the event that the Limits of Insurance provided by this policy exceed the Limits of Insurance
required by the written contract:
x. The insurance provided by this endorsement shall be limited to the Limits of Insurance
required by the written contract; and
y. 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.
XS -21234b (08/13) Includes oopydghted material of Insurance Services Office, Inc., with Its permission. Page 1 of 2
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 terms and conditions.
9ja 0, A-4.,
Authorized Representative
XS -21234b (08/13) Includes copyrighted material of Insurance Services Office, Inc., with Its permission. Page 2 of 2