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PROOF OF INSURANCE (2022) CLOSEDO �® ACC� CERTIFICATE OF LIABILITY INSURANCE DATE /YYYY) �V/ 01/2912021/2021 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 NAME: **Marsh USA, Inc. PHONE FAX 501 Merritt 7 A/C No Ext : A/C No): EMAIL Norwalk, CT 06856-0770 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:ACE American Insurance Company 22667 CN I 02013285-NW-NW-21-22 X Medina INSURED NESTLE WATERS NORTH AMERICA HOLDINGS INC INSURER B : Indemnity Ins Co Of North America 43575 INSURER C : ACE Fire Underwriters Insurance Company 20702 READYREFRESH BY NESTLE INSURER D : ATTN: RISK MANAGEMENT 1812 N. MOORE STREET, STE 3500 ARLINGTON, VA 22209 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: NYC-009682252-17 REVISION NUMBER: 11 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE IX I OCCUR HDOG7156955A 01/01/2021 01/01/2022 EACH OCCURRENCE $ 2,000,000 DAMAGE TO RE PREMISES(E. occurrDence)$ 1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑PRO JECT ❑ LOC OTHER: GENERAL AGGREGATE $ 5,000,000 X PRODUCTS - COMP/OP AGG $ 5,000,000 $ A A A A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY ISA H25311887 (AOS) ISA H25311966 (NEW HAMPSHIRE) ISA H25311929 (CT,FL, IL, KS, LA, NY, OK, VT, VA) XSA H25312004 (XS NH) 01/01/2021 01/01/2021 01/01/2021 01/01/2021 01/01/2022 01/01/2022 01/01/2022 01/01/2022 COMBINED SINGLE LIMIT Ea accident $ 2,000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ UMBRELLALIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ B A G WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under OF OPERATIONS below N/A WLR C6782376A (AOS) WLR C67823801 ( ) AZ, CA & MA SCF C67823849 (WI) 01/01/2021 01/01/2021 01/01/2021 01/01/2022 01/01/2022 01/01/2022 X PER oTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000DESCRIPTION $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Waiver of Subrogation is applicable where required by written contract. CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Maria Cerritos THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD EXEMPTNOTICE: THESE, POLICY FORMS AND THE, APPLICABLE, RATES ARE FROM THE, FILING REQUIREMENTS Yam..R, OF THE NEW O -' RATESINSURANCE LAW AND REGULATIONS. HOWEVER,, THE: FORMS AND STANDARDS t4 i ..yam. INSURANCE LAW i REGULATIONS. ■ ! F THE, NEW !' ND WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS Naimed InsL'ired E n d arse im e in t Nluimldeir Nestle Waters North America Holdings Inc. Ponucy'Syimlbon Poky Number Poniicy Penned Effective Crate of Endorsement 1SA H2 311887 01/01/2021 to 01/01/2022 01/01/2021 Issreied By (Name of Insurance Coimlpany) Acre American Insurance Company insert tine pooucy namtoer, ii ire reimai naer of the intorimanan is to De campgetea onay wnein tnus einaaiiment is ussuea su i eq u eint to the pireparanon of the poiiucy. THIS ENDORSEMENTCHANGES THE POLICY. PLEASE READ IT CAREFULLY. This Endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM' MOTOR CARRIERS COVERAGE FORM AUTO DEALERS COVERAGE FORM e 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 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.. Authorized Representative QA-131 15a, (06/14) Page 1 of 1 NYFTz 2-14057 Nestle Waters North America Moldings, Inc. 01/01/2021 —01/ t1/2022 POLICY NUMBER: MHO G7156955A COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 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 sunder the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person,(s) Or Organization(s). 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 Rigihts Of Recovery. Against Others To Us of Section. IV Conditions: We waive any right of recovery against the person(s) or organizations) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such persons), or organizations), prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 @ Insurance Services Office, Inc., 2018 Page ^I of 1 Workers' Cornpensatiion and Emplovers' Liiabiilllty Pollcv Named Insured Endorsement Number NESTLE WATERS NORTH AMERICA HOLDINGS, INC. 1812 N. lV MORE STREET Policy Number ARLIN TON, VA 22209 Symbol:WLR Number:C67823801 Policy Period Effective Date of Endorsement 01-01-2021 TO 01-01--2022 01-01-2021 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the inforrnation is to be completed only when this endorsement is issued subsequent to the preparation of the policy, EARLIER NOTICE OF CANCELLATION AND NON -RENEWAL ENDORSEMENT' Paragraphs A. and B. below apply to all States shown in item 3.A. of the (Information Page except as indicated below. A. EARLIER NOTICE OF CANCELLATION For any statutorily permitted reason„ other than nonpayment of premium„ the minimum number of days required for notice of cancellation as provided in either the Cancellation Condition of the policy or as amended by any applicable state cancellation endorsement is increased to 90 days. If the state cancellation endorsement provides for more than the number of days notice of cancellation shown above„ this provision does not apply. B. EARLIER NOTICE OF NON -RENEWAL if we decide not to renew this policy for any reason other than non payment of premium„ the minimum number of days for notice of non -renewal as provided by any applicable state non -renewal endorsement is increased to 90 days. If the state non -renewal endorsement provides for more than the number of days notice of non -renewal shown above„ this provision does not apply. State Exceptions ARIYZCNA Not applicable - Paragraph A NEW JERSEY Not applicable VWlSCCNSIVN Not applicable 4 Authorized Agent CK -10290 (3101) P"td. in U.S.A. WC 99 06 97'