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Insurance - Xylem Water Solutions Inc. 2021-12-06act CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/06/2021 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 endorsement(s). PRODUCER CONTACT Marsh USA, Inc. NAME: PHONE FAX 1166 Avenue of the Americas A/c No Ext : (A/C, No): New York, NY 10036 E-MAIL�� — — — _ INSURER(S) AFFORDING COVERAGE _i NAIC # CN108453421-STND-GAWUe-21-22 INSURER A: AIU Insurance Co. 119399 INSURED INSURER B: National Union Fire Ins. Co. 19445 Xylem Water Solutions USA, Inc. -- -------- 4828 Parkway Plaza Blvd: Suite 200 INSURER C : Allianz Global Risks US Insurance Company_________________ 35300 Charlotte, NC 28217 INSURER D : N/A N/A INSURER E : COVERAGES CERTIFICATE NUMBER: NYC-010725554-14 REVISION NUMBER: 8 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 IADDLISUBR! POLICY EFF I POLICY EXP LTR TYPE OF INSURANCE INSD 1 WVD POLICY NUMBER MM/DDIYYYY MM/DD/YYYY LIMITS B j X COMMERCIAL GENERAL LIABILITY GL6547204 10/31/2021 10/31/2022 EACH OCCURRENCE $ 1,0001000 DAMAGE TO RENTED -- CLAIMS -MADE X OCCUR PREMISES (Ea occurrence) S 1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 10,000,000 X 'POLICY JECT PRO- X PRODUCTS -COMP/OP AGG S 6,000,000 - -- OTHER: _-- I SIR: $1;000,000 --- $ ------ B 'AUTOMOBILE LIABILITY CA 7031023 (AIDS) 10/31/2021 10/31/2022 COMBINED accident) SINGLE LIMIT $ 5,000,000 B 1 X ANY AUTO CA 7031024 (MA) 10/31/2021 10/31/2022 BODILY INJURY (Per person) j $ B OWNED ;SCHEDULED CA 7031025 (VA) 10/31/2021 10/31/2022 BODILY INJURY (Per accident)' $ AUTOS ONLY _ AUTOS HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY Per accidenD_____ $ X ;UMBRELLA LIAB X 'OCCUR USL00109921 10/31/2021 10/31/2022 EACH OCCURRENCE $ 5,000,000 ~: EXCESS LIAB CLAIMS -MADE AGGREGATE $ 5,000,000 1 DED X i RETENTIONS 10,000 $ A WORKERS COMPENSATION WC 65885842 (AOS) /3 / 21 10/31/2022 X PER OTH- AND EMPLOYERS' LIABILITY :STATUTE ER A Y / N WC 65885841 (NY) 10/31/2021 10/31/2022 2,000,000 ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ A OFFICER/MEMBER EXCLUDED? ' N / A WC 65885843 WI 10/31/2021 10/31/2022 1 (Mandatory in NH) ( ) E.L. DISEASE - EA EMPLOYEE', $ 2,000,000 A 1 If yes, describe under WC 65885840 (CA) j 10/31/2021 10/31/2022 2,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ i DESCRIPTION OF OPERATIONS 1 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, rI=PTIGIf_ATF wr)i r)FR rANr;=1 I ATIf1N Costa Mesa Sanitary District SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Administrative Services Manager THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 290 Paularino Avenue Pb a if/ -,a, or ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa, CA 92626 AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD A►C ORO`� AGENCY CUSTOMER ID: CN108453421 LOC #: New York nnniTinWeII PPRAADkc cr_WPn1 11 G - -- — ... — - -- -- . ------ -. _. _— — — • • -- — -- AGENCY NAMED INSURED Marsh USA, Inc. Xylem Water Solutions USA, Inc. 4828 Parkway Plaza Blvd, Suite 200 POLICY NUMBER Charlotte, NC 28217 CARRIER ADDITIONAL REMARKS NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 _ FORM TITLE: Certificate of Liability Insurance Panes 7 of ') 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 POLICY NUMBER: CA 7031023 COMMERCIAL AUTO CA 04 49 11 16 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. A. The following is added to the Other Insurance Condition in the Business Auto Coverage Form and the Other Insurance - Primary And Excess Insurance Provisions in the Motor Carrier Coverage Form and supersedes any provision to the contrary: This Coverage Form's Covered Autos Liability Coverage is primary to and will not seek contribution from any other insurance available to an "insured" under your policy provided that: 1. Such "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 such "insured". CA04491116 B. The following is added to the Other Insurance Condition in the Auto Dealers Coverage Form and supersedes any provision to the 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 "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 such "insured". 10 Insurance Services Office, Inc., 2016 Page 1 of 1 n POLICY NUMBER: CA 7031024 COMMERCIAL AUTO CA044Q1116 THUS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: With respect to coverage provided by this endorsement. the provisions of the Coverage Form apply unless modified by the endorsement. A. The following is added to the Other Insurance Condition in the Business Auto Coverage Form and the Other Insurance - Primary And Excess Insurance Provisions in the Motor Corner Coverage Form and supersedes any provision to the oonhary� This Coverage Fonn's Covered Amos Liability Coverage isprimary toand will not seek contribution from any other insurance available to an "insured" under your policy provided that: 1. Such ^insured^iea Named Insured Linder such other insuranne�and 2. You have agreed in writing in a contract or agreement that this insurance would beprimary and would not seek contribution from any other insurance available to such "insured". B. The following is added to the Other Insurance Condition in the Auto Dealers Coverage Form and supersedes any provision bzthe 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 toan^inmured^under your policy provided that: 1. Such "insured^isaNamed Insured under such other insurance; and 2. You have agreed in writing in a contract or agreement that this insurance would beprimary and would not seek contribution from any other insurance available /osuch ''insured" ru, Insurance Services Office, Inc., 2016 Page 1 of I i� POLICY NUMBER: CA 7031025 COMMERCIAL AUTO CAO44Q111S THUS ENDORSEMENT CHANGES THE POLICY. PLEASE READ 0FCAREFULLY. This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect hocoverage provided bythis endorsement, the provisions ofthe Coverage Form apply unless modified by the endorsement. A. The following is added to the Other Insurance Condition in the Business Auto Coverage Form and the Other Insurance ' Primary And Excess |nmunenoa Provisions in the yNuhx Carder Coverage Form and supersedes any provision to the contrary: This Coverage Form's Covered Autos Liability Coverage ieprimary toand will not seek contribution from any other insurance available toen "insured" under your policy provided thet 1. Such "insured" is Named Insured under such other insurance; and 2. You have agreed in writing in a contract or agreement that this insurance would beprimary and would not seek contribution from any other insurance available hzsuch ^inoured^ B. The following is added to the Other Insurance Condition in the Auto Dealers Coverage Form and supersedes any provision tothe contrary: This Coverage Form'a Covered Autos Liability Coverage and General Liability Coverages are primary to and will not seek contribution from any other insurance available tonn"inoured~under your policy provided that: Y. Such "insured" is e Named Insured under such other insurance; and 2 You have agreed in writing in a contract or agreement that this insurance would beprimary and would not seek contribution from any other insurance available tosuch "insured^ -0 Insurance Services Office, Inc., 2016 Page I of 1 101 PCOMMERCIAL AUTO POLICY NUMBER: CA 7031023 CA 04 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Xylem Inc. Endorsement Effective Date: 10/31/2021 SCHEDULE Name(s) Of Person(s) Or Organization(s): Any person or organization for whom the Named Insured is required to provide a waiver I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organ ization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization CA 04 44 10 13 Insurance Services Office. Inc-2011 Page 1 of 1 13 POLICY NUMBER., COMMERCIAL AUT# THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respectto coverage provided by this endoraemerd, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Xylem Inc. Endorsement Effective Date: 10/31/2021 Name(s) Of Person(s) Or Organization(s): Any person or organization for whom the Named Insured is required to provide a waiver information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer C/fRights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) in the Sohaduke, but only tuthe extent that subrogation is waived prior to the "accident" or the "loss" under o contract with that person or organization C&Q4441013 Insurance Services Office, |nc,2O11 Page 1of1 0 POLICY NUMBER: COMMERCIAL AUT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified bythe endorsement. This endorsement ohsngeathepo|ioyeffemtiveondheinoephondakacfVhepoUcyunkaosenotherdaheisindicated below. � Named Insured: Xylem Inc. Endorsement Effective Date: 10131/2021 Name(s) Of Person(s) Or Organization(s): Any person or organization for whom the Named Insured is required to provide a waiver I information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer C]fRights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Sohadule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under e contract with that person o, organization CA 04 44 10 13 Insurance Services Office, Inc-2011 Page I of 1 13 POLICY NUMBER: GL8547204 COMMERCIAL GENERAL LIABILITY CG 20010413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ 0[CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCT S/COM PLETED 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 kz enadditional insured under your policy provided that: (1)The additional insured is e 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 tothe additional insured. CG 20 01 04 13 .0 Insurance Services Office, Inc., 2012 Page I of 1 POLICY NUMBER: GL 6547204 COMMERCIAL GENERAL LIABILITY CG 24 04 0509 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: I If CEO] 000116*9KONTA IN I =1111:111 RX91 219 N.111119 "I'M- 0104 RA IR SCHEDULE Name Of Person Or Organization: Pursuant to applicable written contract or agreement you enter into. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Sec- tion IV - Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing opera- Lions or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 .0 Insurance Services Office, Inc., 2008 Page 1 of I 1 7M WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date iaindicated below. (The following ^ attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12/21 AM 10131/2021 forms part ofPolicy No. VVC85885842 Issued to Xylem Inc. ByA|U Insurance Company 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 ororganization named inthe Schedule. This agreement applies only tothe extent that you perform work under a written contract that requires you to obtain this agreement from us. This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE ENTERED INTO A CONTRACT, A CONDITION OF WHICH REQUIRES YOU TO OBTAIN THIS WAIVER FROM US. THIS ENDORSEMENT DOES NOT APPLY TO BENEFITS OR DAMAGES PAID ORCLAIMED: 1. PURSUANT TO THE WORKERS'COMPENSATION OR EMPLOYERS'LIABILITY LAWS OF KENTUCKY. NEW HAMPSH|RE.DRNEW JERSEY; OR, 2.BECAUSE OFINJURY OCCURRING BEFORE YOU ENTERED INTO SUCH ACONTRACT. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Ohio, Tennessee, Texas, Utah, or Washington. VVCQ00313 Countersigned by Authorized Representative WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT--CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date iaindicated below. (The following ^ attaching clause" need uecompleted only when this endorsement is issued subsequent topreparation orthe mm,ov) This endorsement, effective12.U1 AM 10/31/2021 Issued to Xylem Inc. By AIU Insurance Company forms apart nfPolicy No. VVC85885840 We have the right to recover our payments from anyone liable for an injury covered bythis policy. VVewill not enforce our right against the person ororganizetk/nnemedintho8ohedu|e.(Thisograement applies only tothe extent that you perform work under a written contract that requires you to obtain this agreement from us). You must maintain peynd| records accurately segregating the remuneration of your employees while engaged in the work described mthe Schedule. The additional premium for this endorsement aheU be 2Y6ofthe California workers' compensation premium otherwise due onsuch remuneration. Schedule Person or Organization Job Descrir)tion Any person or organization for whorn the Named Insured has agreed by written contract to furnish this waiver. VVCD4O3O8 Countersigned by______________________________ (Ed.04/84 Authorized Representative ENDORSEMENT This endorsement, effective 12:01 A.M. 1013112021 forms a part of policy No. CA 7031023 issued to Xylem Inc. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -WHERE REQUIRED UNDER CONTRACT OR AGREEMENT This endorsement modifies insurance provided under the following: IMINWINS0,11119i 01 1151 1INT411199 0 X The Costa Mesa Sanitary District, its elected and appointed officials, agents, officers, volunteers and employees. 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 andlor limits of this policy, or (2) The coverage and/or limits required by said contract or agreement. 87950 (10/05) Authorized Representative or Countersi nature (in States Where Applicablej Page 1 of 1 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Pereon(s)Or(]mQonizatmn(s): The Costa Mesa Sanitary District, its elected and appointed officials, agents, officers, volunteers and employees I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section U —VVho Is An Insured is amended to include aaen additional insured the person(s) or organization(s) shown in the 8ohedu|e, but only with respect to liability for "bodily injuryr. "property damage" or "personal and advertising injury" oaused, in whole or in part, by your acts or omissions orthe acts oromissions ofthose acting on your behalf: 1. |nthe performance ofyour ongoing operations; or 2. In connection with your premises owned by or rented to you. 1.The insurance afforded to such additional insured only applies tothe extent permitted by law, and 2. Ifcoverage provided hothe additional insured is required by e oondreo\ or agraemant, the insurance afforded to such additional insured will not be broader than that which you are required by the contractor agreement to provide for such additional insured. B.With respect to the insurance afforded to these additional inaunads, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreemem, the most we will pay on behalf ofthe additional insured is the amount ofinauranoe� 1. Required bythe contract cxagreement; ur 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is |oeo. This endorsement shall not increase the applicable Limits ofInsurance shown in the Declarations. CG 20280413 @ Insurance Services Office, |nn,2O12 Page I of I