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PROOF OF INSURANCE (2013) CLOSED.lCµ- oRr CERTIFICATE OF LIABILITY INSURANCE DATE(MMI ° °/YYY "' 10/09/2012 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 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 C WACt MARSH USA, Inc. NAME; ........... .. 601 MERRITT 7 to C NNU hxt) ................... _... .. ,,. � (AA/C, No): NORWALK, CT 06856 -6010 EMAIL Attn: Norwalk.certrequest @Marsh.com Fax: 212 - 948 -0929 APQR° ., ........ ° INSURERS) AFFORDING COVERAGE I 071217 -NW- CAS -12 -13 CARDE INSURER A: ACE American Insurance Company 22667 INSURED INSURER B Indemnity Ins Co Of North America 43575 ARROWHEAD DRINKING WATER CO, �_, ®.... ... CIO NESTLE WATERS NORTH AMERICA, INC. INSURER C : 900 LONG RIDGE ROAD /BUILDING 2 INSURER D: STAMFORD, CT 06902 -1138 n ... -................. ._, INSURER E COVERAGES CERTIFICATE NUMBER: NYC - 006480740 -03 REVISION NUMBER:5 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, INSIR �.. n.. 1INSR 5l1♦D PO9.ICY EXP TYPE OF INSURANCE POLICY NUMBER MM1DD/YYFF YY MMI'DO /YyyY LIMITS A GENERAL LIABILITY HDOG26437052 01/01/2012 01/0112013 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL X LIABILITY IJAMA6L Yb RENTED ��� 1,000,000 (Fa occti }rrenc�) $ CLAIMS MADE X _PREMISE q 10,000 .d OCCUR (Any one person) $ PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 1,000,000 X POLICY Pfd; LOC $ A AUTOMOBILE LIABILITY ISAH08693912 0110112012 01/01/2013 COMBINED D SiN01 E LIMIT 2000,00 XI ANY AUTO (Laa ccmni9, m._ m.. BODILY INJURY (Per person) $ ALL OWNED SCHEDULED ''.AUTOS AUTOS BODILY INJURY P er accident) ( ) $ NON -OWNED HIRED AUTOS AUTOS PROPERYY DAMA4�4: $ (Per ggcJd1e1!0 ®eee... _ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE ...., m ... e „ ...I ,.._ .,_......._... AGGREGATE $ DED I 41, RETENTION $ ..$ ,.,..�.,. _........ .,....,. B WORKERS COMPENSATION - WLRC46776185 (AOS) 0110112012 01/01/2013 X.. WC STATU OTH AND EMPLOYERS' LIABILITY Y / N A ANY PROPRIETOR /PARTNER /EXECUTIVE WLRC46776173 (CA & MA) 01/01/2012 01/01/2013 l TORY LIMITS ER E L EACH AC $ 1,000,00 ACCIDENT OFFICER /MEMBER EXCLUDED? N A (Mandatory in NH) N/A SCFC46776197 (WI) ; 01/0112012 01/01/2013 E L DISEASE - EA EMPLOYEE, $ 1,000,000 Y If DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I 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 HOLD CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: CITY CLERK THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO, CA 90245 -0989 '.. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. I Kristy A. Dreher -ep— I'I- d �--- ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: HDO G26437052 ENDT. #77 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following, COMMERCIAL- GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) An —Own, wn,e _.. .. ., ..o a ion- _ l..t to s Y Lessee or Connract.or whom All locations and operations r r a�ntzation s - Location And Des tion Of Coma feted O eration you have agreed to include as an °Perations o£ the Named Insured.. additional insured under a written contract, Provided such contract a executed prior to the date of 1 sa. on r eratuired to Section It – Who Is An Insured is amended to include as an additional insured the person(s) or organixatlo,n(s) shMn in the Schedule, but only with respect to liability for ®bortrly injury' or property darnage" caused, in whote 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 till "prodricts- r 0fnpleted operations hazard ". be scav�u� in the l�etarations. a we wnai,... CG 20 37 07 04 r5 IS30 Properties, tile., 2004 Page 1 of T POLICY NUMBER: HDO 626437052 ENDT. #43 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — OWNERS, LESSEES OR CONTRACTORS — SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or arnzation s _. .... g, _i_ ); a ocation � of Covered Operations _ Any Owner, Lessee or Contractor whom you All locations and operations of the have agreed to include as an additional Named insured. insured under a written contract, provided such contract was executed prior to the date of loss. tr)forrnation recjuired to co et ^ this Schedule, if not shown above, will to shown in the Declarations. A. Section Ii — Who Is An Insured is amended to B. With respect to the insurance afforded to include as an additional insured the person(s) or these additional insureds, the following organization(s) shown in the Schedule, but only will) additional exclusions apply; respect to liability for "bodily injury" "property damage" or "personal and advertising injury" This insurance does not apply to "bodily injury" caused, in whole or in part by: or "property damage" occurring after: 1. Your acts or omissions; or 1. All work, including materials, parts or equipment furnished in connection with 2. The acts or omissions of those acting on your such work, on the project (other than behalf; service, maintenance or repairs) to be performed by or on behalf of the additional in the performance of your ongoing operations for insured(s) at the location of the covered the additional insureds) at the locations) operations has been completed; or designated above. 2. That portion of `your work' out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a par! of the same pi-eject CG 20 10 07 04 ISO Properties. Inc., 2004 Page 1 of 1 Workers' Compensation and Employers' Liability Policy N rrr�ee l p t rc d - Endorsement �kuoiber- _.... .. Ww NESTLE WATERS NORTH AMERICA HOLDINGS, INC. ity N 1 Number Number: C4677618m icy Nrn�aer 900 LANG RIDGE ROAD BLpG. 2 5 _; ,_ ...... ....... . ._, _ _.... d. �.- � r olicy I eaii zd Effective Date of E.__.. _.._....�_... ndorsement 01 -01-2012 TO D1 -01 -2013 01 -01 -2012 Issued t3y ��deme of I����ar,ce �r�mgsa�eay� INDEMNITY INS. CO. OF NORTH AMERICA W-� F.' "' ! the i rfcc�i� insert td a �crtit numoer fho t �r�aii� #a .__ s to fir, rrafslet r trig wMen this enderserwtent is issued st,Pbseai w WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT of the 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 on no arned in the Schedule. Schedule ANY PER SON OR CI<.GANiZA'I` ON AGA1- dST iA'HOM YOU _ -THAVE AGREED TO r1j=i`.1-VE YOUR RIC, --l'a OF RECOC.Tr_ R`1 -LN A `'?.TT Eiv CONTRACT, PiaoVIDED U',-'H CONTRAC`41' riVkS EXECUTED PRLC? "VC THE I'?s,`PE OF LOSS For the states of CA, LIT. TX, refer to state specific endorsements, This endorsement is not applicable in KY, NH, and NJ. Authofized Aaent 33221 _. —_mw __ _ _ WC 00 03 13 (11/05) d. U.S.A. Copyright 1982 -83 National Council ..... vn Compensation Workers' NESTLE WATERS NORTH AMERICA HOLDINGS, INC. 900 LONG RIDGE ROAD, BLDG. 2 F�olicy Period�� _ .... 01 -01 -2012 TO 01 -01 -2013 lesued b Name of insurance empany) ACE AMERICAN INSURANCE COMPANY Insert the taei Sy number The Qaa warrcir r ... of the information is to be and Employers' Liabifity Pol . E ...ndorsem,, _ ._ ..._.... ..�. ent Number- Po icy Number Syplbcol. WLR Number: 046776173 Effective Date of Endorsement 01 -01 -2012 when INS endorsement is issj)ed subsequent is the tare�aa toil of 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 11 ION1 YOU HAVE AGREED TO Wl-,IVE `` UI RIGHT OF' RECOVERY IN A 'NfRIT°? EN CONTRACT, PROVIDED SUCH O` °3bTr1'RTC WAS EX.E,CTUE`i PRIOR TO THE DATE OF ',')SS For the states of CA: UT, TX. refer to state specific endorsements. � This endorsement is not applicable in KY. NH. and NJ. 1 r � LJAk .,......u_a_,. AUthorized..Ac WC 00 00 03 13 (i V05) Ptd. U S.A. Copyright 1882 -83; National Council on Compensation Workers' Com Named Insured NESTLE WATERS NORTH AMERICA HOLDINGS, INC. 900 LONG RIDGE ROAD, BLDG. 2 OI1G FEnod a1 -01 -2413 Issued By (Nartte of f(ostsrance Company} _ACLU AMERICAN INSURANCE COMPANY trued the policy number. The remainder Wit oie i forrnation i.,t l€ n and 1= ntent Employers' Liability Policy Number Policy Number rwt oa SCF Number: C46776197 Effective hake cf et'n 01 -01 -2012 when tftr etmct rrsern �rrt Issued s�tl ~,s quent to pile rr feoara4o.. ratuan of the 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 ORGAN A'� L °7N? firFIIIV?' a ,O%i `.it�u I °IA�:�: AGREED 7 f® v7AT�JE �'CUE� F�II?T °Jr T�C.�T.7EEY IN A "uVRITTl, C °vNPPf?.F vT, PROVIDED SUCH CONTRACT WAS XF CUTED PR -10R T!) THE DATE O .,CSS For the states of CA; UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. Authorized Agent )513 URIC; 00 03 i3 {1 l/ j i t k. U S A. Copyright 1982 -83, National Council on Compensation �mm umW I" � .