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Insurance - Xylem Inc. - 2013 �1 ® DATE(MM/DD/YYYY) q ° CERTIFICATE OF LIABILITY INSURANCE 03/26/2013 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 be endorsed. If SUBROGATION IS WAIVED,subject to m the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the t certificate holder in lieu of such endorsement(s). c • PRODUCER CONTACT d Aon Risk Services Northeast, Inc. PHONE FAX New York NY Office (A/C.No.Ext): (866) 283-7122 I(A/C.No.): (847) 953-5390 199 Water Street E-MAIL ) New York NY 10038-3551 USA ADDRESS: _ INSURER(S)AFFORDING COVERAGE - NAIC# INSURED INSURER A: ACE American Insurance Company 22667 Xylem, Inc. INSURER B: Flygt 11161 Harrell Street INSURER C: Mira Loma CA 91752 USA INSURER 0: INSURER E: INSURER F: - - COVERAGES CERTIFICATE NUMBER:570049357000 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 INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR wVD POLICY NUMBER (MM/DD/YYYY) `MM/DDIYYYY LIMITS A GENERAL LIABILITY XSLG27014628 10/31/201210/31/201 EACH OCCURRENCE $1,000,000 SIR applies per policy terns & conditions DAMAGE TO RENTED $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) CLAIMS-MADE ©OCCUR MED EXP(Any one person) Excl uded PERSONAL&ADV INJURY $1,000,000 8 . GENERAL AGGREGATE $10,000,000 N- GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $6,000,000 v 71 POLICY IIJECT LOC - SIR - $1,000,000 0 A ISA H08712025 10/31/2012 10/31/2013 COMBINED SINGLE LIMIT in AUTOMOBILE LIABILITY (Ea accident) $1,000,000 X ANY AUTO " BODILY INJURY(Per person) 0 ALL OWNED -SCHEDULED BODILY INJURY(Per accident) 2 AUTOS _ AUTOS HIRED AUTOS NON-OWNED PR ECRdT nI;AMAGE w AUTOS f N UMBRELLA LIAB OCCUR EACH OCCURRENCE 0 EXCESS LIAB CLAIMS-MADE AGGREGATE DED I RETENTION _ - A WORKERS COMPENSATION AND WLRC47127191 10/31/2012 10/31/2013 WC STATU- OTH- EMPLOYERS'LIABILITY Y/N WC All Other States X TORY LIMITS ER ANY PROPRIETOR - '�' OFFICER/MEM ER EXCLUDED?EXECUTIVE N NIA SCFC47127208 10/31/2012 10/31/2013 E.L.EACH ACCIDENT $2,000,000 (Mandatory in NH) WC WI Only E.L.DISEASE-EA EMPLOYEE $2,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S2,000,000 EMI its DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Costa Mesa Sanitary District is included as Additional Insured in accordance with the policy provisions of the General Liability policy. M • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. aj�2 yrir Costa Mesa Sanitary District '\`\/ AUTHORIZED REPRESENTATIVE 628 W. 19th Street `\('(t` Costa Mesa CA 92627 uSA /v�\ rifir RE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: XSLG27014628 ENDT. #4 ADDITIONAL INSURED —DESIGNATED PERSON OR ORGANIZATION Named Insured Endorsement Number Xylem Inc. 4 - Policy Symbol Policy Number Policy Period Effective Date of Endorsement XSL G27014628 10/31/2012 to 10/31/2013 10/31/2012 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. 5.J This endorsement modifies insurance provided under the following: !_s EXCESS COMMERCIAL GENERAL LIABILITY POLICY SCHEDULE Name of Person or Organization: Any person or organization whom you have agreed to include as an additional insured under a written contract, provided such contract was executed prior to the date of loss. SECTION II — WHO IS AN INSURED is amended to include as an additional insured the person(s) or ti 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. A. In the performance of your ongoing operations;or B. In connection with your premises owned by or rented to you. • sr • f Authorized Representative Includes copyrighted material of Insurance Services Office, Inc.with its permission XS-6W25a(06/10)