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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" � .