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Insurance - Xylem Water Solutions, Inc. 2019-11-14ACC>R" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/ODNYYY) 11/14/2019 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 CONTACT Lauren Giangrande NAME:PHONE(212) 345-6000 I FAx A/c No Ext : A/C NoJ:_ E-MAIL ADDRESS: Lauren.Giangrande@marsh.com New York, NY 10036 INSURER(S) AFFORDING COVERAGE ! NAIC # INSURER A: See Acord 101 CN108453421-STND-GAW-19-20 INSURED Xylem Water Solutions USA, Inc. INSURER B: National Union Fire Ins. Co. ' 19445 i INSURER C : 1 14125 South Bridge Circle Charlotte, NC 28273 INSURER D : INSURER E: 1,000,000 INSURER F: �i:1:Ad1:1refrd=1111JIIIky,1_1y- 1►7ggiTiFiILOVLOI a�L• . , 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. ILTR TYPE OF INSURANCE NSR AN DD SUBRI WVD POLICY NUMBER POLICY EFF LICY EXP MM DDNYYY MM DDNYYY LIMITS B i X 1 COMMERCIAL GENERAL LIABILITY GL 6862456 110/31/2019 10/31/2020EACH OCCURRENCE I $ 1,000,000 CLAIMS -MADE ! X !OCCUR DAMAGE TO RENTED ( PREMISES Ea occurrence $ 1,000,000 11 MED one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 EN'L AGGREGATE LIMIT APPLIES PER:I GENERAL AGGREGATE ! $ 2,000,000 X POLICY JECOT- L LOC I PRODUCTS -COMP/OP AGG ! $ 2,000,000 OTHER: SIR: $1,000,000 $ B AUTOMOBILE LIABILITY CA 5320316 (AOS) 10/31/2019 10/31/2020 COMBINED SINGLE LIMIT $ Ea accident 3,000,000 B X I ANY AUTO 1 CA 5320317 (VA) 10/31/2019 110/31/2020 BODILY INJURY (Per person) $ B OWNED F, SCHEDULED AUTOS ONLY �� AUTOS I CA 5320318MA ( ) 10/31/2019 11013112020 BODILY INJURY (Per accident) * $ HIRED i NON -OWNED L_ AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ i Per accident $ UMBRELLA LIAB OCCUR j ! EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE i AGGREGATE $ t $ DED RETENTION $ 1 A 1 WORKERS COMPENSATION SEE ACORD 101 10/31/2019 110/31/2020 ; X , PER j OTH- AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y / N N / A a STATUTE ER I E.L. EACH ACCIDENT $ 2,000,000 OFFICER/MEMBER EXCLUDED? . (Mandatory in NH)! I E.L. DISEASE - EA EMPLOYEEi $ 2,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below ( 1 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) Re: All operations Costa Mesa Sanitary District, their elected and appointed officials, agents, officers, volunteers, and employees 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. CERTIFICATE HOLDER CANCELLATION Costa Mesa Sanitary District 290 aAvenue Costaa Mesa, CA 92626 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Lauren Giagrandeo,,.r�co rv�d ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ACOR" L -- AGENCY CUSTOMER ID: CN108453421 LOC #: New York ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Marsh USA, Inc. NAMED INSURED Xylem Water Solutions USA, Inc. 14125 South Bridge Circle Charlotte, NC 28273 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: IF-, NJIILei � G111111111:4= THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, I FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance WORKERS COMPENSATION CARRIER: NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608516 (AOS) CARRIER: NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608517 (IL, KY, NC, NH, UT, VT) CARRIER: NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608518 (NJ, PA) CARRIER: NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608519 (MA, OH, WA, WI, WY) CARRIER: AMERICAN HOME ASSURANCE POLICY: WC 020608520 (CA) CARRIER: ILLINOIS NATIONAL INSURANCE COMPANY POLICY: WC 020608521 (FL) CARRIER: NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608522 (AZ, VA) ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ENDORSEMENT This endorsement, effective 12:01 A.M. forms a part of policy No. 532-03-16 issued to Xylem Inc. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. "-1 This endorsement modifies insurance provided under the followin3: BUSINESS AUTO COVERAGE FORM F-11 SCHEDULE Any person or organization for whom you are contractually bound to provide Additional Insured status. But only to the extent of such person's or organization's liability arising out of use of a covered "auto". L SECTION 11 - LIABILITY COVERAGE, A. Coverage, 1. - Who Is Insured, is amended to add: d. Any person or organization, shown in the schedule above, to whom you become obligated to include as an additional insured under this policy, as a result of any contract or agreement you enter into which requires you to furnish insurance to that person or organization of the type provided by this policy, but only with respect to Liability arising out of use of a covered "auto". However, the insurance provided will not exceed the Lesser of: (1) The coverage and/or limits of this policy, or (2) The coverage and/or Limits required by said contract or agreement. 87950 (10/05) Authorized Representative or Countersienature (in States Where Applicable-) Page 1 of 1 POLICY NUMBER: [4532-0B-16 COMMERCIAL AUTO CA 044911 18 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. well 9 : 1 :9 koz R, i6qi I I kDEW, WD4491 gAff, 40L: DINO[* %I This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM 8LB|NESS AUTO COVE RAG EFORN\MOTOR CARRIER COVERAGE FORM Wth respect to coverage provided bythis endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. A. The following is added to the Other Insurance Condition inthe Business Auto Coverage Form and the Other Insurance - Primary And Excess Ummmnmnce Provisions in the Motor Carder Coverage Form and supersedes any provision to the contrary: This Coverage Form's Covered Autos Liability Coverage is primary to and Mii not seek contribution from any other insurance available to an'lnsured^under your policy provided that: 1. Such 'insured^is a Named Insured under such other insurance; and Z You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to such CA 0449 11 16 B. The following is added to the Ocher Insurance Condition in the Auto Dealers Coverage Form and supersedes any provision tothe contrary: This Coverage Form's Covered Autos Liability Coverage and General Liability Coverages are primary to and will not seek contribution from any other insurance available to an 'Insured" under your policy provided that: 1. Such 'lnsured''is a Named Insured under such other i nsu rance; and 2. You have agreed in vvhdng in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to such 0 Insurance Services Office, Inc., 2016 Page 1 of 1 �Mi POLICY NUMBER: GL 686-24-56 COMMERCIAL GENERAL LIABILITY CG 20010413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIARR'T'AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART 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 will not seek contribution from any other insurance available to an additional insured under your policy provided that: (I)The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: GL 686-24-56 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. W 1 0 • :J:J :UTOI ki go] Mel M - This endorsement modifies -insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): ANY PERSON OR ORGANIZATION WHOM YOU BECOME OBLIGATED TO INCLUDE AS AN ADDITIONAL INSURED AS A RESULT OF ANY CONTRACT OR AGREEMENT YOU HAVE ENTERED INTO. I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 — Who 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. H owever: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. 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. 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 0413 @ Insurance Services Office, Inc., 20312 Page 1 of 1 Ale6MR P `� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/31/2019 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 CONTACT NAME: Lauren Giangrande PHONE (212) 345-6000 FAX A/c No Ext): A/C No : New York, NY 10036 E-MAIL ADDRESS: Lauren.Giangrande@marsh.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: See Acord 101 CN108453421-STND-GAW-19-20 INSURED Xylem Water Solutions USA, Inc. INSURER B: National Union Fire Ins. Co. 119445 INSURER C : 14125 South Bridge Circle Charlotte, NC 28273 INSURER D INSURER E : INSURER F ( EM9101=rv,Ten=. 01=ra11:211W,1111= 0 I I I ivi ic-»vjL*-4r llWIIi,r,I-»-arr 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 TYPE OF INSURANCE LTR ADDL SUBR� N POLICY NUMBER ; POLICY EFF MM/DDIYYYY POLICY EXP MM/DD/YYYY LIMITS B X COMMERCIAL GENERAL LIABILITY GL 6862456 110/31/2019 110/31/2020 EACH OCCURRENCE $ 1,000,000 CLAIMS OCCUR DAMAGE TO RENTED 1,000,000 -MADE �— PREMISES (Ea occurrence) $ , TMED ( EXP (Any one person) j $ 10,000 _ PERSONAL & ADV INJURY$ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000'000 X POLICY E ECT (_; LOC PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER: SIR: $1,000,000 $ B AUTOMOBILE LIABILITY CA 5320316 (AOS) 10/31/2019 10/31/2020 COMBINED SINGLE LIMIT $ 3,000,000 B T Ea accident ANY AUTO CA 5320317 (VA) 10/31/2019 10/31/2020 BODILY INJURY (Per person) $ B OWNED SCHEDULED AUTOS ONLY AUTOS j CA 5320318 (MA) 10/31/2019 10/31/2020 BODILY INJURY (Per accident) $ HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ DED I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY i SEE ACORD 101 / 10/31/2020 X !PER STATUTE EORH ANYPROPRIETOR/PARTNER/EXECUTIVE Y / N E.L. EACH ACCIDENT $ 2,000,000 OFFICER/MEMBER EXCLUDED? N❑ N /A (Mandatory in NH) E. L. DISEASE - EA EMPLOYEEI $ 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) Re: All operations Costa Mesa Sanitary District, their elected and appointed officials, agents, officers, volunteers, and employees 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. 6t:K I WIL A 1 t: MULUMK GANGtLLATIUN 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Lauren Giagrande o'�nr`.o,w.co�rv�D ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN108453421 LOC #: New York ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Marsh USA, Inc. NAMED INSURED Xylem Water Solutions USA, Inc. 14125 South Bridge Circle Charlotte, NC 28273 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS ITHIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, I FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance WORKERS COMPENSATION CARRIER: NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608516 (AOS) CARRIER: NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608517 (IL, KY, NC, NH, UT, VT) CARRIER: NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608518 (NJ, PA) CARRIER: NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608519 (MA, OH, WA, WI, WY) CARRIER: AMERICAN HOME ASSURANCE POLICY: WC 020608520 (CA) CARRIER: ILLINOIS NATIONAL INSURANCE COMPANY POLICY: WC 020608521 (FL) CARRIER: NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608522 (AZ, VA) ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD