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Insurance - Xylem Water Solutions USA Inc.ACORN°CERTIFICATE OF LIABILITY INSURANCE EDATE /YYYY) 09/05/2019/2019 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 have ADDITIONAL INSURED provisions or 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 Marsh USA, Inc. 1166 Avenue of the Americas New York, NY 10036 CONTACT NAME: PHO (A/CNo Ext): i IA/C No E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: ACE American Insurance Company j 22667 CN108453421-STND-GAWUe-18-19 INSURED Xylem Water Solutions USA, Inc. INSURER B: ACE Fire Underwriters Ins. Co. e 20702 INSURER C: Allianz Global Risks US Insurance CompaWny 35300 4828 Parkway Plaza Blvd, Suite 200 Charlotte, NC 28217 INSURER D : Indemnit Insurance Com an of North America � ; 43575 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMRER- NY(-n1n795554-n1 RFVIQIr)NI mi lunGR• 1 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. INSR ADDL SUBR POLICY EFF I POLICY EXP LTR TYPE OF INSURANCE IND POLICY NUMBER MM/DD/YYYY MM/DD/YYYY ! LIMITS C X COMMERCIAL GENERAL LIABILITY USL00107118 110/31/2018 110/31/2019 ' EACH OCCURRENCE j $ 1,000,000 I DAMAGE TO RENTED CLAIMS -MADE OCCUR1,000,000 PREMISES (Ea occurrence) l $ MED EXP (Any one person) $ 10,000 J j ! PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000 _ EX POLICY JPRODUCTS -C -- 6,000,000LOC OMP/OP AGG 1$ ;OTHER: ! j SIR: $1,000,000 is A AUTOMOBILE LIABILITY 1 11SA H25272754 10/31/2018 10/31/2019 COMBINED SINGLE LIMIT $ 3,000,000 X ANY AUTO Ea accident BODILY INJURY (Per person) I $ -1 OWNED r ' SCHEDULED BODILY INJURY Per accident AUTOS ONLY AUTOS i i ( ) $ HIRED �? NON -OWNED ;PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY i (Per accident) $ I i I Is - X UMBRELLA LIAB X ;OCCUR USL00109918 10/31/2018 10/31/2019 5,000,000 EACH OCCURRENCE $ j EXCESS LIAR I I CLAIMS-MADE'l 1 AGGREGATE $ 5,000,000 DED X RETENTION $ 10,000 $ D WORKERS COMPENSATION WLR C65437065 (AOS) / I 10/31 /2019 X 'PER OTH- AND EMPLOYERS' LIABILITY Y / N STATUTE ( ER B ANYPROPRIETOR/PARTNER/EXECUTIVE j SCF C65437107 (WI) 10/31/2018 ;10/31/2019 2,000,000 OFFICER/MEMBER EXCLUDED? a N / A E.L. EACH ACCIDENT $ A Mandato ) WLR C65437028 CA, MA, OR 1 10/31/2018 110/31/2019 (Mandatory in NH ( ) E.L. DISEASE - EA EMPLOYEE $ 2,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 2,000,000 I ' I DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Costa Mesa Sanitary District., their elected and appointmented officials, agents, officers, volunteers, and employees (Pursuant to attached endorsements) are included as additional insured (except Workers Compensation) as required by written contract. This insurance is primary and non-contributory over any existing insurance and limited to liability arising out of the operations of the named insured and where required by written contract. Waiver of Subrogation is applicable where required by written contract and as permissible by law. CERTIFICATE HOLDER CANCELLATION Costa Mesa Sanitary District SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 290 Paularino Avenue � THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa, CA 92626 ,y 1(j/i1 ACCORDANCE WITH THE POLICY PROVISIONS. �101 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. i Lauren Giagrancle ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD [I ADDITIONAL INSURED — DESIGNATED PERSONS OR ORGANIZATIONS Named Insured Xylem Inc. Endorsement Number 4 Policy Symbol Policy Number Policy Period 01 Indorsement ISA H25272754 10/31MI8 To 10/31/2019 'ks-u-e-d- S --y- (Name of Insurance Company) ACE American Insurance Company 'fa ri th-ap-o-Aicy number The remainder of the Information 4 to be complotad 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: BUSINESS AUTO COVERAGE FORM AUTO DEALERS COVERAGE FORM MOTOR CARRIER COVERAGE FORM EXCESS BUSINESS AUTO COVERAGE FORM Additional Insured(s)-. Any ggrson .or organization whom you have sl wed to include as an gdditional insured under a written contract. 2roviQed.§MgJ1 contract was executed prior to the date of toss. A. For a covered "auto," Who Is Insured is amended to include as an "insured," the persons or organizations named in this endorsement, However, these persons or organizations are an "insured' only for "bodily injury' or "property damage" resulting from acts or omissions of. 1. You. 2. Any of your `employees" or agents, 3. Any person operating a covered "auto" with permission from you, any of your "employees" or agents, B. The persons or organizations named in this endorsement are not liable for payment of your premium. Autho-r—ii-s-d'k4-p'r--e--s--e-'n-t-a'-t'ive DA -91174c (03116) Page 1 of 1 q11 UA t&%191 INL 0 M A. SectionWho Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. W 1 � — , Dwever: 1. The insurance afforded to such d oappadditionj insurenly lies to e pe thextent rmitted law; and CG 20 26 04 13 2. If coverage provided to the additional insured iz-5 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.B.With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 9) Insurance Services Office, Inc., 2012 Page I of ' Named Insured Endorsement Number XYLEM INC. 1 INTERNATIONAL DRIVE Policy Number RYE BROOK NY 10573 Symbol, VVLR Number: 065437065 Policy Period Effective Date of Endorsement 10-31-2018 TO ioe31-21719 10-31-2018 Issued By (Name of Insurance Company) 3.0 INDEMNITY INS, CO. OF NORTH AMERICA 13. E, Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subseguent to thepl�rpRaration of the policy. THE INSURED'S MAILING ADDRESS PAS BEEN REVISED TO READ: XYLEM INC. 1 INTERNATIONAr, DRIVE RYE BROOK,NY 10573 Aitharized Representative WC 99 06 OOB (08/14) Includes copyright material of the National Council on Compensation CKE-IU76K-- Insurance, Inc. used with its permission. Page 1 of '41 11-09-2018 NYU INSURED COPY POLICY INFORMATION PAGE ENDORSEMENT The following item(s) 1- El Insureds Name 11. Item 3.8. Limits 2. L] Policy Number 12. El, Item 3,C, States 3.0 Effective Date 13. E, Item 3.D. Endorsement Numbers 4. F] Expiration Date 14. [] Item 4, *Class, Rate, Other 5. Insured's Mailing Address 15, ❑ Interim Adjustment of Premium 6. ❑ Experience Modification 16, carrier servicing Office 7. Producer's Name 17. Ej Interstate/ Intrastate Risk ID Number 8. Change in Workplace(s) of Insured 18. F1 Carrier Number 9. El insured's Legal Status 19. El issuing Agency/Producer Office Address 10. E- 1 Item 3.A. States is changed to read: THE INSURED'S MAILING ADDRESS PAS BEEN REVISED TO READ: XYLEM INC. 1 INTERNATIONAr, DRIVE RYE BROOK,NY 10573 Aitharized Representative WC 99 06 OOB (08/14) Includes copyright material of the National Council on Compensation CKE-IU76K-- Insurance, Inc. used with its permission. Page 1 of '41 11-09-2018 NYU INSURED COPY worKers-;-ompensation ane hmployers' Liability Policy Named Insured Endorsement Number XYLEM ENC. 1133 WESTCHESTER AVENUE Policy Number WHITE PLAINS NY 10604 Symbol. WLR Number, 065437028 Policy Period Effedive Date of Endorsement 10-31-2018 TO 10-31-2019 10-31-2018 Issued By (Name of Insurance Company) LACE AMERICAN INSURANCE COMPANY 1 -.Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued Subsequent to the pro aration of tine policy. A This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. the Information Page. i We have the right to recover our payments from anyone liable for an injury covered by this policy. We will n enforce our right against the person or organization named in the Schedule, but this waiver applies only with respe to bodily injury arising out of the operations described in the Schedule, where you are required by a written contra to obtain this waiver from us. I You must maintain payroll records accurately segregating the remuneration of your employees while engaged in th work described in the Schedule. 5 Specific Waiver Name of person or organizatiol X Blanket Waiver Any pers®n or organization for whom the Named Insured has agreed by written contract to furnish this waiver, ALL OPERATIONS CONDUCTED BY AN INSURED PURSUANT TO SUCH WRITTEN CONTRACT The premium charge for this endorsement shall be 2.0 percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. Authorized Representative L IT PRE 1191 Policy Number: USLOO107118 Effective Date: October 31, 2011 ADDITIONAL INSURED —WHEN REQUIRED BY WRITTEN CONTRACT Including Prod ucts-Completed Operations Hazard This endorsement modifies insurance provided under the following: A. Section 11 —Who is an Insured is amended to include any person or organization you are required to include as an additional insured on this policy by a written contract or written agreement in affect during this policy pedod and executed prior to the "occurrence" of the injury or damage but only to the extent required by the terms and conditions of such written contract or written agreement. The insurance provided to the above descdbed addonal insured under this endorsement is limited as follows: 1 - The person or organization is only an addonal insured with respect to liability arising out of ongoing operations performed by you or an your behalf or arising out of your "products -completed operations hazard". 2. In the event that the Limits of Insurance provided by this policy exceed the Limits of Insurance required by the written contract or written agreement, the insurance provided by this endorsement sh be limited to the Limits of Insurance required by the written Contract or written agreement, This endorsement shall not increase the Limits of Insurance shown in the Declarations pertaining to the coverage provided herein, I 3. The insurance provided to such an additional insured does not apply to "bodily injury"property damage" or 'personal and advertising injury" arising out of an architect's, engineers or surveyor's rendering of or failure to render any professional services, including, but not limited to: (a) The preparing, approving or faiting to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders,, change orders, or drawings and specifications and (b) Supervisory, inspection, architectural or engineering activities. 4. This insurance cloes not apply to "bodily injury" or "property damage" arising out of "your work" or a your prodUCtn included in the 'product -completed operations hazard" unless you are required to provide such coverage by written contract or written agreement and then only for the period of time required by the written contract or written agreement and in no event beyond the expiration date of the policy. Any coverage provided by this endorsement to an additional insured shall be excess over any other vali and collectible insurance available to the additional insured whether primary, excess, contingent or on a other basis unless the written contract specifically requires that this insurance apply on a primary or non- contributory basis, I All other terms and conditions remain unchangeN AG RL -CG 6002 (04-10) Page I of I Named In Xylem Inc. Endorsement Number 19 Policy Symbol Policy Number Policy Period Effeclive Daae of Endotsemen( ISA IH25272754 11013112018 To 10131/2019 Issued By (Name of Insurance Company) ACE American Insurance Company W4;n inik)pnc7t nimtr,.a. i no remainder i: iie jniofmatioo is to be completed or4y when this endorsement Is issued ftbs"uenj 40 the Preparation of ths poli THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Organization Additional Insured Endorsement Any additional insured with whom you have agreed to provide such non-contributory insurance, pursuant to and as required under a written contract executed prior to the date of loss. (if no informahon is filled in, the schedule shall read: "All persons or onfilies added as additional insureds through an endorsement with The latm "Additional Insured" in the title) For organizations that are listed in the Schedule above that are also an Additional Insured under an endorseme attached to this policy, the following is added to the Other Insurance Condition under General Conditions: If other insurance is available to an insured we cover under any of the endorsements listed or describ above (the 'Additional Insured') for a loss we cover under this policy, this insurance will apply to such 101 *n a primary basis and we will not seek contribution from the other insurance available to the Addition Insured, Authorized Representative DA -21886b (06114) Page 1 of 1 AimnR-32M. Owe Tr; 3M i I I -DMJ#7x&fi The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and wili not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 0104 13 (2) You have agreed in writing in a contract or agreement that this insurance would be pdmary and would not seek contribution from any other insurance available to the additiotral iisured. CG 21 0104 13 Q Insurance Services Office, Inc., 2012 Page I of I