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Insurance - Xylem Water Solutions, USA, Inc. 2019-01-04A►DATE o� CERTIFICATE OF LIABILITY INSURANCE (MM/DD/YYYY) 01/04/2019 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 Gian rande NAME: g PH AIC NNo Ext): (212) 345-6000 FAX No): EMAIL ADDRESS: Lauren. Giangrande@marsh.com New York, NY 10036 INSURER(S) AFFORDING COVERAGE NAIC # USL00107118 INSURER A: ACE American Insurance Company 22667 CN108453421-STND-GAWex-18-19 INSURED Xylem Water Solutions USA, Inc. 14125 South Bridge Circle INSURER B: ACE Fire Underwriters Ins. Co/ 20702 INSURER C : Indemnity Insurance Company of North America e/ 43575 INSURER D: Allianz Global Risks US Insurance Company 35300 Charlotte, NC 28273 INSURER E: DAMAGERENTED 1,000,000 PREMISESS ( Ea occurrence $ INSURER F: COVERAGES CERTIFICATE NUMBER: NYC -010192912-04 REVISION NUMBER: 12 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. INSRLICY LTR TYPE OF INSURANCE IVSD SWVD UER POLICY NUMBER EXP MM DDY/YYYY MEFF M! D/YYYY LIMITS D X COMMERCIAL GENERAL LIABILITY USL00107118 10/31/2018 110/31/2019 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE I " OCCUR ! ( DAMAGERENTED 1,000,000 PREMISESS ( Ea occurrence $ MED EXP (Any one person) $ 10,000 1 PERSONAL & ADV INJURY $ 1,000,000 I AGGREGATE LIMIT APPLIES PER: GGEE GENERAL AGGREGATE $ 2,000,000 1N'L ^ POLICY ECT D LOC PRODUCTS - COMP/OP AGG $ 2,000,000 SIR: $1,000,000 $ OTHER: ( A AUTOMOBILE LIABILITY ISA H25272754 10/31/2018 ii 10/31/2019 COMBINED SINGLE LIMIT $ Ea accident 3,000,000 BODILY INJURY (Per person) $ X ANY AUTO OWNED SCHEDULED AUTOS ONLY FAUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY ( PROPERTY DAMAGE Per accident)$ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE _ I DED RETENTION $ $ C B A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A WLR C65437065 (AOS)10/31/2179-10/31/2019 SCF 065437107 WI ( ) WLR C65437028 CA, MA, OR ( ) 10/31/2018 10/31/2019 10/31/2018 10/31/2019 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 2,000,000 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 I j 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 Paularino Avenue SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa, CA 92626 ACCORDANCE WITH THE POLICY PROVISIONS. t 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 Narnad Insured Xylem Inc ement Number bol !Policy Number Pol" Period I Effectwe Date of Endorsement ISA 11-1252727541 1 10/3112018 To 10131/2019 Issued By (Name of Insurance Company) ACE American Insurance Company IM'Sed the policy number ne remainder c(he information 4 to be cmplttvd on Y wrien til.is snJorseri'lill is issued subsequent to ttw prieloarallilion of the poill.1 HURY--w2l iiiiiijillillill III I 1111111111111111111111 lill Jill 11 1111111111111111111111 l�� lill Additional Insured(s)., Any Derso, or organization wh d under a written contract. vmvided-suc-h contract was executed prior to the date of loss. Fk For a covered 'auto," Who Is Insured is amended to include as an "irisured," 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 act$ or omissIlions 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. 8. The persons or organizations named in this endorsement are not liable for payrnent of your premium. Authorized Representative DA -91.174c (03116) Page 1 of 1 POLICY NUMBER: USLOO107118 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART NNEIMM A. Section 1) — 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" C@used, 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 additioni insured only applies to the extent permitted law-, and 2If 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: I . 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 ®r- Insurance Services offirce, Inc., 2012 Page 1 of 1 NON-CONTRIBUTORY ENDORSEMENT FOR ADDITIONAL INSUREDS Pol.-cy Syrnboal I Pol "c Nwmbef ISA li'H25272754 i sju*d By (Nana of I naurame Company) ACE American Insurance Company lrsert Ma pchcV number- Tha rvemamder j$ Policy Perod 10131M18 TO 10131/2019 IN THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM AUTO DEALERS COVERAGE FORM W Or.93—r1!Z—atri Additional Insured Endorsement Any additional irisur.ed with whom you have agreed to provide such non-contrilbutory insurance, pursuant lo and as required under a written contract executed for to the date of toss, 'if no info rm.ation is in, me -schedule $hail taad, "All persons Lw, caildies addedas ad a; n, isnsu d -O & thraugh an endmement vOth It term 'Addala on al b�sored` Y) thetiffe) For organizations that are listed in the Schedule above that are also an Additional Insured under an endorsernerst attached to this polivy, the folfovving is added to the Other Insurance Condition under General Conditions: If other insuranre is available to an insured we cover under any of the endorsements listed 01, described above (the "Additional Insured') for a loss we cover under this policy, this insurance will apply to such loss or,a primairy basis and we will riot seek contribution from the other insurenCle available to the Additional Insured. Auflhoflzed R=epresenlafive DA -21886b (0604) Page 1 of I 'CeOMMERCIAL GENERAL LIABILITY CG 20 0104 13 This endorsement modifies insurance provided under the followina: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTSICOMPLETED 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, (1) 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 pdr,riary and would not, seek contribution from any other insurance available to the additional insured, CG 20 0104 13 Oc Insurance Services Office, Inc., 2012 Page I of I