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Insurance - Xylem Water Solutionss USA, Inc. 2019-11-15AC'CW HDATE 16*.�CERTIFICATE OF LIABILITY INSURANCE (MM/DD/YYYY) 11115/2019 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: A/cC No Ext): FAA/c No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: See Acord 101 CN108453421-STND-GAWUe-19-20 INSURED Xylem Water Solutions USA, Inc. INSURER B: National Union Fire Ins, Co. 119445 INSURER C: Allianz Global Risks US Insurance Company 135300 4828 Parkway Plaza Blvd, Suite 200 Charlotte, NC 28217 INSURER D: INSURER E : INSURER F: <RMITIMZ#ACt;�► 94=:AII=IM,911=kgIIIkviIV=M -J!ATJL-1ral\■\1111,1-7!4-a► 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. INSRi ADDLiSUBRi POLICY EFF POLICY EXP 1 LTR TYPE OF INSURANCE p POLICY NUMBER 1 IMM/DD/YYYY)MM/DD/YYYY i LIMITS B X COMMERCIAL GENERAL LIABILITY GL 6862456 10/31/2019 i 10/31/2020 iEACH OCCURRENCE $ 1,000,000 _� CLAIMS -MADE i X OCCUR DAMAGE TO RENTED 1,000,000 �_— _� 1 PREMISES (Ea occurrence) $ _ MED EXP (Any one person) t $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ 10,000,000 PRO- JECT RO X I POLICY ^' JECT LOC PRODUCTS-COMP/OP AGG $ 6,000,000 OTHER: SIR: $1,000,000$ B ! AUTOMOBILE LIABILITY CA 5320316 AOS 110/31/2019 1 10/31/2020 :COMBINED SINGLE LIMIT r — (AIDS) $ 3,000,000 B X ANY AUTO CA 5320317 VA 10/31/2019 110/31/2020 (Ea accident) _ � � i � I ( ) ! ;BODILY INJURY (Per person) $ B 1 OWNED SCHEDULED I CA 5320318 (MA) ! 10/31/2019 10/31!2020 BODILY INJURY (Per accident); $ AUTOS ONLY AUTOS _ I HIRED NON -OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ X UMBRELLA LIAB X OCCUR USL00109919 10/31/2019 110/31/2020 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS -MADE j AGGREGATE $ 5,000,000 DED X RETENTION $10,000 $ A WORKERS COMPENSATION !SEE ACORD 101 10/31/21019 10/31 /2020 X 1 PER OTH- AND EMPLOYERS' LIABILITY Y / N I STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE 2,000,000 OFFICER/MEMBER EXCLUDED? N / A E.L. EACH ACCIDENT $ (Mandatory in NH) I E.L. DISEASE - EA EMPLOYEE' $ 2,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below f E.L. DISEASE - POLICY LIMIT $ 2,000,000 ! i i I i 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. GtK I II IUA I C t'IULUtK GANGELLATION Costa Mesa Sanitary District SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 290 Paularino Avenue ✓(')� j, % THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa, CA 92626 ��// 1 /� ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Lauren Giagrande ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD =I' 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. 4828 Parkway Plaza Blvd, Suite 200 Charlotte, NC 28217 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, 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) Each of the insurance policies referenced above provides that should such policy be cancelled by the insurer before the expiration date thereof for any reason other than nonpayment of premium, the insuring company will endeavor to mail 30 days written notice thereof to the certificate holder (except 10 days for non-payment of premium), but failure to provide such notice shall impose no obligation or liability of any kind upon the insurer or its agents or representatives, will not extend any policy cancellation date and will not negate any cancellation of the policy. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD This endorsexnent,effective 12:01 A.M. forms apart of policy No. 532-03-16 issued to Xylem Inc. By NATIONAL UNION FIRE INSURANCE COMPANY OFPITTSBURGH, PA THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under thefo/lowin3: BUSINESS AUTO COVERAGE FORM SCHEDULE Any person ororganization 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 U - LIABILITY COVERAGE, A. Coverage, 1. - Who Is Insured, is amended to add: cL Any shown in the schedule above, towhom 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 wiiinot exceed the Lesser of: (1) The coverage and/or limits ofthis policy, or (2) The coverage and/or limits required by said contract or agreement. Authorized Representative or 87950 (10/05) POLICY NUMBER: GL 686-2.4- 6 r*Je1JPzv1z:JsJKK1 M.'11 ! ••' '' ! 16 1 1 • 1 0 r * IN 0: 0 , IFAFAII 9 o This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1,'01.I: Ibill q 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 Inform ation required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — 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. However: 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 04 13 Insurance Services Office, Inc., 2012 Page 1 of 'I y This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaciing clause" need be completed only mhlen tips endorsement is issued subsequent to nres�aration of tree poi cy} This endorsement, effective 12:01 AM 10/31/2019 Issued to Xylem Inc. By American Home Assurance Company Premium forms a part of Policy No. WC 020008520 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us). You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. #/-7�PL7� C040306 Countersigned by-------------------------.___.__ (Ed. 04/84) Authorized Representative