No preview available
PROOF OF INSURANCE (2021) CLOSEDATE OC CERTIFICATE OF LIABILITY INSURANCE D12/06/2019D/YYYY) �1 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 Ethem D oklc C * Marsh USA, Inc, ann,Et......................__ ..._ 1 501 Merritt 7 NC o f I: 212-345-7942 I f a Nq1: Norwalk, CT 06856-0770 E-MAIL ethem.d okic marsh.com ADDREss: j @ INSURERS)FF AORDING COVERAGE NAIC # ____ - ... INSURER A : ACEAmericanInsurance Company, 22667 .. CN102013285-NW-GAW-20.21 X CARDE mmm mm ...... ......_... INSURED NORTHNESTLE WATERS ERICA HOLDINGS INC INSURER B: Indemnity Ins Co Ol NOrth America 43575 READYREFRESH BY NESTLE INSURER C: ACE Fire Underwriters Insurance Comoanv 120702 ATTN: RISK MANAGEMENT Ns R R E INSURER 1812 N. MOORE STREET, STE 3500 U ARLINGTON, VA 22209 I ._ X.D........:.._. INSURER F COVERAGES CERTIFICATE NUMBER: NYC -009685701-27 REVISION NUMBER: 36 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. ILTR TYPE OF INSURANCE ADUOVOINSD WVD POLICY NUMBER fMM/DD/YYYYITIMMIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY HDOG71233546 01/01/2020 01/0112021 EACH OCCURRENCE $ 1000,000 l CLAIMS -MADE L..X..w� OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: 01/01/2020 P88., 01/01/2020 _X POLICY JEOI' LOC BODILY INJURY (Per accident) $ OTHER WLR C66037'733 (AOS) AUTOMOBILE LIABILITY WLR C66037770 (AZ, CA & MA) .... A ANY AUTO SCF C66037812 (WI) A OWNED EACH OCCURRENCE $ SCHEDULED .,••••••••m- AUTOS ONLY AUTOS HIRED II II II NON -OWNED ,••,,,,,,,,,,•• AUTOS ONLY AUTOS ONLY A UMBRELLA LIAB OCCUR I EXCESS LI AB CLAIMS -MADE DED I V RETENTION $ B WORKERS COMPENSATION A AND EMPLOYERS' LIABILITY Y / N ANYPROPRi ETOR/PARTNER/EXECUTI VE O OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below ISA H25286649 (AOS) 01/01/2020 ISA H25286728 (NEW HAMPSHIRE) 01/01/2020 ISA H25286686 01/01/2020 (CT,FL, IL, KS, LA, NY, OK, VT, VA) BODILY INJURY (Per accident) $ XSA H25286765 (XS NEW HAMPSHIRE) 01/0112020 WLR C66037'733 (AOS) 01/0112020 WLR C66037770 (AZ, CA & MA) 01/01/2020 SCF C66037812 (WI) 01/01/2020 t7bi�l;A a� ��'"ffkE]NTrzb REMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL &ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ 01/01/2021 COMBINED SINGLE LIMPT $ 01/01/2021 BODILY INJURY (Per person) $ 01/01/2021 BODILY INJURY (Per accident) $ 11 ..................... ........ _...._ . � PROPERTY DAMAGE Per urELd��rll 1 ... 01/0112021 $ EACH OCCURRENCE $ AGG.REGATE......................_...................... $ $ 01/01/2021 II II II 01/01/2021 .X ..I.5787.+gL.....l.......,...I .E_F� E L EACH ACCIDENT $ 01/01/2021 E L DISEASE - EA EMPLOYEE $ EL DISEASE - POLICY LIMIT $ 1,000,000 10,000 1,000,000 2,000,0 00 1,000,000 2,000,000 1,000.000 1,000,000 ........... 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CITY OF EL SEGUNDO IS INCLUDED AS ADDITIONAL INSURED (EXCEPT WORKERS COMPENSATION) WHERE REQUIRED BY WRITTEN CONTRACT, WAIVER OF SUBROGATION IS APPLICABLE WHERE REQUIRED BY WRITTEN CONTRACT. CERTIFICATE HOLDER CITY OF EL SEGUNDO ATTN: CITY CLERK 350 MAIN STREET EL SEGUNDO, CA 90245-0989 ACORD 25 (2016/03) 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. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: HDO 671233546 Nestle Waters 1-1-20 to 21 COMMERCIAL GENERAL LIABILITY CG 20 37 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE: THESE POLICY FORMS AND THE APPLICABLE RATES ARE EXEMPT FROM THE FILING REQUIREMENTS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. HOWEVER, THE FORMS AND RATES MUST MEET THE MINIMUM STANDARDS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED, OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization( Location And Description Of Completed Operations Any person or organization whom you have agreed to All locations and operations of the Named Insured. include as an additional insured under a written contract, provided such contract was executed prior to the date of loss. Information 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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". 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. CG 20 37 1219 © Insurance Services Office, Inc., 2012 Page 1 of 2 Class Code 2-14057 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. Page 2 of 2 ® ISO Properties, Inc., 2004 CG 20 37 12 19 ❑ Class Code 2-14057 NOTICE TO OTHERS ENDORSEMENT ~~SCHEDULE Nestle Waters North America Holdings, Inc. -- Endorsement Number 18 icy Symbol Policy Number Policy Period -- Effective Date oyEndorsement HDO |G71233548 1/01/2020 TD 01/01/2021 Issued 8y(Name o,Insurance Company) - ---------' - ------------------ AOEAmmriman|nsurmnmyCompmny ---Tnswi 11he policy nuMbOF, The remaiiider oJthe infonn*uvm/wtvmwcompieted only when this endorsement is'x�ad subl;eqventTo the ptepri,abonpt'mwnlAc', A. Ifmmcancel the Policy prior to its expiration date by notice to you or the first Named insured for any reason other than nonpayment ufpremium, wxewill endeavor, mmset out below, tosend written notice cfcancellation, via such electronic or other form of notification as we debarminw, to the persons or organizations Uohmd in the schedule that you or your napnaean|adiva provide or have provided to us (the "Schedule"). You or your napnamentaUms must provide us with the physical and/or e-mail address of such persons or organizedione, and we will utilize such a'mmil oddnwaa or physical address that you oryour representative provided touaonsuch Schedule. B. The Schedule must beinitially provided touswithin 15days after: L The beginning ufthe Policy period, ifthis endorsement iseffective aoofsuch date; or ii. This endorsement has been added to the Poicy, if this endorsement is effective after the Policy period C. The Schedule must boinanelectronic format that isacceptable tous; and must boaccurate. C. Our delivery of the notification as described in Paragraph A. of this endorsement will be based on the most recent Schedule in our records as of the date the notice of cancellation is mailed or delivered to the first Named Insured, E. We will endeavor to send or deliver such notice to the e-mail address orphysical address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the canueUsdkm date applicable to the F. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of o pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) ororQwnizaUon(a) shown in the Schedule shall impose no obligation or liability of any kind upon um` our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation ofthe Policy, G. We are not responsible for verifying any information provided to us in any Schedule, nor are woresponsible for any incorrect information that you or your representative provide to us. If you or your uaPnaoentodivo does not provide us with a Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail and physical address information with respect toa particular person or o[Qanizmtipn, then we shall have no responsibility for taking action with regard to muoh person or entity under this endorsement. H. VVemay arrange with your representative to send such notice in the event of any such cancellation. U. You will cooperate with us in providing the Schedule, or in causing your representative to provide the Schedule. ALL -32687 (05/11) Page 1 of 2 All other terms and conditions of the Policy rernain unchanged, d— R"' ' e" p" i " e"' " s- e-, 'n- ia"I' i v e" ALL -32687 (05M I) Page 2 of 2 POLICY NUMBER: HDO 671233546 Nestle Waters 1-1-20 to 21 COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 NOTICE: THESE POLICY FORMS AND THE APPLICABLE RATES ARE EX- EMPT FROM THE FILING REQUIREMENTS OF THE NEW YORK INSUR- ANCE LAW AND REGULATIONS. HOWEVER, THE FORMS AND RATES MUST MEET THE MINIMUM STANDARDS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO SDS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Any person or organization against whom you have agreed to waive your right of recovery in a written contract, provided such contract was executed prior to the date of loss. 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 Section 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 operations 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 12 19 © Insurance Services Office, Inc, 2008 Page 1 of 1 ❑ Class Code 2-14057 NOTICE: THESE POLICY FORMS AND THE APPLICABLE RATES ARE EXEMPT FROM THE FILING REQUIREMENTS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. HOWEVER, THE FORMS AND RATES MUST MEET THE MINIMUM STANDARDS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS Named Insured Endorsement Number Nestle Waters North America Holdings, Inc. Policy Symbol Policy Number Policy Period Effective Date of Endorsement ISA H25286649 1/1/2020 to 1/1/2021 1/1/20-21 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. This Endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIERS COVERAGE FORM TRUCKERS COVERAGE FORM GARAGE COVERAGE FORM We waive any right of recovery we may have against the person or organization shown in the Schedule below because of payments we make for injury or damage arising out of the use of a covered auto. The waiver applies only to the person or organization shown in the SCHEDULE. SCHEDULE 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. Authorized Representative DA -13115a (06/14) Page 1 of 1 Class Code 2-14057 Workers'Compensation and Employers' Liability Policy Named Insured Endorsement Number NESTLE WATERS NORTH AMERICA HOLDINGS, INC. Policy Number 1812 N. MOORE STREET Symbol: WLR Number: 065037770 Policy Period Effective Date of Endorsement 01-01-202o TO 01-01-2021 01-01-2020 Issued By (Name, of Insurance Company) W.. ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is ,o be romploted only when Ihis endoriernenl is, issued subs ��_.._. '. quant to the preparetiorE off the pa1Fcy_„ WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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. This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(8) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. Authorized Agent ..... _........_.. __.. WC 00 03 1-3'(11/05) 0 Copyright 1983-2017 National Councii on Compensation insurance, Inc. AU Rights Reserved. Workers' f 'on pewarlion and Vnipl'oyers` Lia bilily Policy" Named Insured Endorsement Number Nestle Waters North America Holdings, Inc, Policy Number Symbol: WLR Number: 066037770 Policy Period Effective Date of Endorsement 1/1/2020 TO 1/1 /2021 1-1-20 Issued By (Name of Insurance Comhauy) ACE American Insurance Company Insert 0it poticy� waunitier 'clic vm wilider cif the iatiminition is to tic colntr9cled %wily aw�bcn INS cndor�(Iliwt is is Aced st ka;cgaweauw to file turair;wa iwtii7wi of"tiwc poli.) CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. 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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. Schedule 1. ( ) Specific Waiver Name of person or organization: ( X ) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver 2. Operations: where required by contract 3. Premium: The premium charge for this endorsement shall be i l i c l percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Minimum Premium: NA Audio ilxd Agent WC: 90 03 75 (05/18)