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Insurance - Xylem Water Solutions Inc. 2021-11-02A/' �r p �® C40 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 11102/2021 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 endomement(s). PRODUCER Marsh USA, Inc. 1166 Avenue of the Americas CONTACT NAME: PHONE F� Noll: ADDRESS: New York, NY 10036 RECEIVE INSURERS AFFORDING COVERAGE NAIC INSURER A: AIU Insurance Co. 19399 CN108453421-STND-GAWUe-21-22 IN Xylem Water Solutions USA, Inc. NUV 122 ( 4828 Parkway Plaza Blvd, Suite 200 INSURER B: National Union Fire Ins. Co. 19445 INSURER C : Allianz Global Risks US Insurance Company 35300 INSURER D: N/A N/A Charlotte, NC 28217 C t)51:a Mesa INSURER E: INSURER F MED EXP (Any one person) $ 10,000 COVERAGES CERTIFICATE NUMBER: NYC -010725554-11 REVISION NUMBER: 4 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. 1NSR TR TYPE OF INSURANCE ADDL SUER POLICY NUMBER Y EFF MM/ /YYYY D POLICY / D/YYYY LIMITS B X COMMERCIAL GENERAL LIABILITY GL 6547204 10/31/2021 10/31/2022 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE a OCCUR REMDAMAGE T RENTED PREMEa occurrence $ 1,000,000 PREM MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,001,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10,010,000 X POLICY � PRO r LOC JECT PRODUCTS - COMP/OP AGG $ 6,000,00) SIR: $1,000,000 $ OTHER: B AUTOMOBILE LIABILITY CA 7031023 (AOS) 10/31/2021 10/31/2022 EeDiSINGLE LIMIT $ 5,000,000 Ea COMBINED B X ANY AUTO CA 7031024 (MA) 10/31/2021 10/31/2022 BODILY INJURY (Per person) $ B OWNED SCHEDULED AUTOS ONLY AUTOS CA 7031025 (VA) 10/31/2021 10/31/2022 BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ Per accident) X UMBRELLA LIAB X OCCUR USL00109921 10/31/2021 10/31/2022 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 EXCESS LIAB CLAIMS -MADE DED X I RETENTION $10,000 $ A A A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECU I IVE nY / N OFFICER/MEMBER EXCLUDED? N (Mandatory in NH) N / A WC 65885842 (AOS) WC 65885841 (NY) WC 65885843 (WI) 10/31/2021 10131/2021 10/31/2022 10/3112022 10/31/2022 X I PEROTH- STATUTE ER E.L. EACH ACCIDENT $ 2,000,000 E.L. DISEASE - EA EMPLOYEE $ 2,000,000 A If yes, describe under DESCRIPTION OF OPERATIONS below WC 65885840 (CA) 10/31/2021 10/31/2022 E.L. DISEASE - POLICY LIMIT $ 2,000,000 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 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 Attn: Administrative Services Manager SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 290 Paularino Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa, CA 92626 AUTHORIZED REPRESENTATIVE zG.S1_4 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD