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PROOF OF INSURANCE (2015) CLOSEDAgreement No. 4585 Nestle Waters North America, Inc. DATE(MMIDDIYYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 01/30/2014 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 Ifhe 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 CONTAET MARSH USA,Inc. NAME. 501 MERRITT 7 (A19!N.Exit" (A/C N,ol� NORWALK,CT 06856-6010 E—MAIL . Aftn:Norwalk.certrequest@Marsh.com Fax: 212-948-0929 ADDRESS, INSURER(S)AFFORDING COVERAGE NAIC# 071217-NW-CAS-14-15 CARDS INSURER A:ACE American Insurance Company 22667 INSURED Indemnity Ins Co Of North America 43575 ARROWHEAD DRINKING WATER CO. INSURER B' C/O NESTLE WATERS NORTH AMERICA,INC. INSURER C; ATTN: RISK MANAGEMENT INSURER D 800 N BRAND BOULEVARD _.. .. .. .......... .. ...... ... „ GLENDALE,CA 91203 M : : ..E................................................................_...................__....................................................................... .................... ................ INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-006480740-12 REVISION NUMBER:20 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,. _..� ...m... 1111-1­11,11--­.., .URANCE .....,we wvn ....... POLICY ........ _...... ,,.._...__�. .....---.�_ ...._,m,��mm____._. IN TYPE OF INS��....�... ����� At�15L�"i'7"efi POLICY EFF POLICY EX���T Y NUMBER (MM/DD/YYYYI (MMIDDIYYYYI LIMITS A GENERAL LIABILITY HDOG2732910A 0110112014 01101/2015 EACH OCCURRENCE $ 1,000,000 X LIABILITY 1,000,000 COMMERCIAL GENERAL PREMISES EaogLLaer1cM $ CLAIMS-MADE X.. OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ��� � �� �� - � ... _—, �umm�WWW������uu�uu�� PRODUCTS COMPIOPAGG $ ,000,000 ..._.. POLICY G � APPLIES f�q�...IG .. ..... .000,. . X F FfiCJ,.. LOC $ A AUTOMOBILE LIABILITY ISAH08816001 01/01/2014 0110112015 G PABINED 1NGLE LIMIT 2,000,000 X ANY AUTO BODILY INJURY(Per person)mm $mm ......... ALL OWNED SCHEDULED _....._. �.. AUTOS AUTOS BODILY INJURY(Per accident) $ _ NON-OWNED PROPERTY DAMAOE ........... ........................................... HIREDAUTOS AUTOS ;;P. M�­`!:mm..fl....................................................$........................................................................ UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATEuuuuWWWWWWWWWWW OED T RETENTION$ $ B WORKERS COMPENSATION WLRC47876084(AOS) 01101/2014 01101/2015 X I WC STATU- OTH- AND EMPLOYERS'LIABILITY E L EACH A„.e . �_. A YIN WLRC47876072(AZ,CA&MA) 01/0112014 01101/2015 EACH III CID F 1,000 000 OFFICER/MEMBER EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE N N/A ACCIDENT $ A (Mandatory in NH) SCFC47876096(WI) 01/0112014 0110112015 EL,DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L,DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,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 CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN:CITY CLERK �r THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 MAIN STREET 1 M ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO,CA 90245-0989 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Kdsty A, Dreher -- ©1988-2010 ACORD CORPORATION. All rights reserved.. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: HDO G2732910A Endorsement Number. 49 CO1I MERCIIAL GENERAL LJABILITY CG 20 37 07 tl4 THIS ENDORSEMENT CHANGES TIME POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — OWNERS, LESSEES OR CONTRACTORS — COMPLETED OPERATIONS ' ,n This endorsement modifies Insure provided under the following, a COMMERCIAL GENERAL LIABILITY COVERAGE PART om SCHEDULE Name Of Additional Insured Parson(s) Or Omani lon(s): Location And DescrioWn Of Completed Operations Any Owner,Lessee or Contractor whom you have All locations and operations of the Named Insured. agreed to Include as an additional insured i under a written contract,provided such contract was executed prior to the date of loss. Information,re uired to complete this edule,if not shown above will be shown In the larations. Section 11 — 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 y'or"property dam- age" caused, In whole or In part, by "your work'" at the location designated and described in the sched- ule of this endorsement perforrried for that additional insured and included in the "products-completed operations hazard". CG 20 37 07 04 0 ISO Properties,Inc.,2004 Page 9 of I AWN NOTICE TO OTHERS, ENDORSEMENT SCHEDULE wmma Nestle Waters North America Holdings,, Inc. i 64 POICY Poiky Mu bor Pokcipedod E Dale Lt H 62732910A ec u" e ay Name rma ra ) �o flltlCth ACE American Insurance Company THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. A. if we cancel the Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium,we will endeavor,as set out below,to send written notice of cancellation,via such electronic or other form of rmfification as we determine,to the persons or organisations listed in tt�s�edule that you or your representative provide or have pmwawmfded to us -Sctwedu ", you or your representative must provide us with the Physical and/or e-mail address of such persons or organizations, and we will utilize such e-mail address or physical, address that you or your representative provided to us on such Schedule, D. The Schedule must be initially provided to us within 16 days after:: 1. The beginning of the Policy,period,if this endorsement is effective as of such date;or I1. This endorsement has been added to the Policy, if this endorsement is effective r the Policy period commences. C. The Schedule must be in an electronic format that is acceptable to us;and must be accurate. D. 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 carwellation Is mailed or delivered to the first Named Insured. E. We will endeavor to send or deliver such nolka to the e-mall address or physical address corresponding to each person or organization indicated In the Schedule at least 30 days prior to the cancellation date applicable to the Policy. 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 a pending cancellation of coverage. We have no legal obligation of any kind to any such on(s) or o ization(s). Our failure to provide advance notification of cancellation to time person(s) or organizations) s In the Schedule ,shall impose no obligation or liability of any kind upon us, our agents or representatives, will' not extend any Policy cancellation date and will not negate any cancellation of the Policy. 6. We are not responsible for veril'ying any Information provided to us In any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative domes not provide us with a Schedule,we have no responsibility for tanking any action under this endorsement. In addition,If neither you nor yours representative provides us with a-snail and physical address information with res to a particular person or organization, then we shall have no responsibility for taming action with regard to such person or entity under this endorsement. H. We may arrange with your representative to send such notice in the event of any such cancellation. I. You will cooperate with us in providing the Schedule,or in causing your representative to provide the Schedule. J. This endorsement does not apply in the event that you cancel the Policy. ALL-32687(05111) Page t of 2 AEI other temes and conditions of the Policy remain unchanged. Authodeed Ropmenftfi" ALL-32687(05111) Page 2 of 2 Workers'Com d E mployars"Liability Policy 0 .. __ pensation an I r l M d _ rntl�sr one�t Nub WESTLE WATERS NORTH ARICA HOLDINGS, INC. 9� RIDGE ROAD, BLDG. 2 o Rtiirba ST� CT .,• 06902 Number ,47876 i 2 _ ' n 01-0I-20 e��fi va l�cr' xict er rl r�'eld' 14 TO O1--a1-2015 01-01-2014 � Issued By iNi of in i camps n��.�____ [ACr-Ai�7 i 1C N INSURANCE COMPANY � In laroarrrk ,r. 4L rn[nrai�r trta lm l t G,nnad R� thra a1n�+turit is issued subUs 4sbrrr W"On 1wlia . CAUFORIVIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by (lie 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. kya iaill t7oi enforce our right against the person or organization darned in the Schedule, but this waiver z(pplies 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 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: 3. Premium: _ The premium charge for this endorsement shall be 2 . 0 percent of the Callfori-Ila prem1um devplopod on payroll in connection with work performed for the above person(s) or organizations)arising out of the operations described. 4. Minimum Premium: .5 0 Aulharlzed lkeprweiftflva -IMIC 99 03 22 _..... �_w ... Hoqate, Richard From: Garcia, Angelina Sent: Thursday, January 30, 2014 8:03 AM To: Hogate, Richard Cc: Shilling, Mona Subject: RE: CITY OF EL SEGUNDO CERTIFICATE- Nestle Arrowhead Approved. Angelina Garcia -----Original Message----- From: Hogate, Richard Sent: Thursday, January 30, 2014 7:32 AM To: Garcia, Angelina Cc: Hogate, Richard Subject: FW: CITY OF EL SEGUNDO CERTIFICATE - Nestle Arrowhead Hi Angie, Please find the attached current insurance information for Nestle Arrowhead Waters for your review and possible approval? Thank you, J. Richard Hogate I Purchasing Agent Office: 310-524-2339 1 Fax: 310-322-2756 P Print less = paper free and tree happy. -----Original Message----- From: Marsh.Certificate @marsh.com [mailto:Marsh.Certificate @marsh.com] Sent: Thursday, January 30, 2014 7:23 AM To: Hogate, Richard Subject: CITY OF EL SEGUNDO CERTIFICATE Reply To : norwalk.certrequest @marsh.com PLEASE DO NOT REPLY TO THIS EMAIL. USE THE REPLY-TO EMAIL ADDRESS INSTEAD. THIS IS A POST-ONLY MAILING. MAIL SENT TO THIS ADDRESS CANNOT BE ANSWERED. **********************************************************************