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PROOF OF INSURANCE (2019) CLOSED DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE I 01/3112018 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(les)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 501arsh Mer Merritt 7'Inc. PHONE FAX No,IIn?rt1: (AIC,fa1r,): Norwalk,CT 06856-0770 E-MAIL Attn:Nolwalk.certrequest@Marsh.com Fax: 212-948-0929 ABORESS. „ INSURER(S)AFFORDING COVERAGE NAIC# 071217-NW-CAS-18-19 X CARDS INSURER A:ACE American Insurance Company 22667 INSURED INSURER 13:Indemnily Ins Co Of North America 43575 NESTLE WATERS NORTH AMERICA,INC. READYREFRESH BY NESTLE INSURER C:ACE Fire Underwriters Insurance Company 20702 800 N BRAND BOULEVARD GLENDALE,CA 91203 )NsuRER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-009685701-23 REVISION NUMBER: 35 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 TYPE OF INSURANCE IADDL'�SUBR POLICY EFF POLICY EXP LTR IWvp POLICY NUMBER (MMIDWY'Y'YYtlM,� MIDDffY'YYI LIMITS A X COMMERCIAL GENERAL LIABILITY HDOG27874836 01/0112018 01/01/2019 EACH OCCURRENCE $ 1,000,000 bAMAG(1'1CJAF1111"ED CLAIMS-MADE $ i3OUa,00a X I OCCUR PREM,IS2'�.;'if!;",acC;CurrerKc ) MED EXP(Any one person) S 10,000 PERSONAL&ADV INJURY S 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY I I PRO- ( TICK..: PRODUCTS $ 1,000,000 l l u:;1 l OTHER: I $ A AUTOMOBILE LIABILITY ISA H25098584 (AOS) 01/0112018 01/01/2019 LIMN $ 2,000,000 (Ea ac[.idllnly X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED ISA H25098596 (NEW HAMPSHIRE) 01/01/2018 01/01/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED Applies to Non-Owned/Hired Vehicles PROPI-,WrY DAMAGE � AUTOS ONLY AUTOS ONLY (Por,accr dont) $ OCCURUMBRELLAILIAB EACH OCCURRENCEEXCS CLAIMS-MADE AGGREGATE S DED ES LIAB C RE......... TENTION S _ $ B WORKERS COMPENSATION WLRC 64626176(AOS) )1101%2018 0110V2019 X PER OIH- ANYPR PRIET R/PARTU E AND EMPLOYERS'LIABILITY YIN NIA ( ) EACSTATH ER 1000000 A Mand O®RI nTNH/PARTNER/EXECUTIVE SCFC64626119A!W)&MA 01101(2018 0110112019 E L DISEASEACCIDENT $ G 1,000,000 ( ry ) """""� -EAEMPLOYEE�I $ If yes,describe under 1,0OO,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I 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 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. Marie Massello /n ; @ 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: HDO 627874836 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 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(s) Location And Description 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 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 1. The insurance afforded to such additional include as an additional insured the person(s) or insured only applies to the extent permitted by organization(s) shown in the Schedule, but only law; and with respect to liability for "bodily injury" or 2. If coverage provided to the additional insured is "property damage"caused, in whole or in part, by required by a contract or agreement, the "your work" at the location designated and insurance afforded to such additional insured will described in the Schedule of this endorsement not be broader than that which you are required performed for that additional insured and by the contract or agreement to provide for such included in the "products-completed operations additional insured. hazard". However: CG 20 37 04 13 © 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 07 04 0 Class Code 2-14057 2 NOTICE TO OTHERS ENDORSEMENT—SCHEDULE wumwumnvned Nestle VVoborm North America Holdings,Inc. E��dii me'WI-Number 2 Policy Symbol pm/q/wvmmo,---------- �mmv��m ��covn�mo��msnmont |MDO IG27874836 01/01/2018 To 01/01/2018 Issued By(wmme'�1-4�i��e7tompany) |ACE American lmmmnonoe Company Insert the noflicynumber.The remwmuw,vfthe Information/*mme completed only when/hiwo=aw,ummem�s Issued subsequent mftpreparation mthe wxkx� ......... THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ U1[CAREFULLY. A. If we umnom|the Policy prior to its ompinoUnn date by notice to you or the first Named insured for any n»moon other than nonpayment oYpremium, we will endamvor, as met out below,to send written notice of cancellation,vim such electronic orother form of notification as we determine, to the persons mrorganizations listed in the schedule that you or your vepneuanboUvm provide or have provided to us (the"Schedule'). You or your representative must provide us with the physical and/or e-mail oddmoma of such persons or organizations, and we will uU|ioo such e-mail address orphysical address that you oryour representative provided bmueomsuch Schedule. B. The Schedule must beinitially provided Vmumwithin 15days after: I. The beginning of the Policy period,if this endorsement is effective as of such date;or Ii. This endorsement has been added to the PoUuK. N this endorsement is effective after the Policy period commences. C. The Schedule must be|nanelectronic format that|aacceptable tous;and must bwaccurate. D. Our delivery of the notification as described in Paragraph Aof this endorsement will be based on the most rmuemd 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 o, deliver such nnUnm to the e-mail address or physical address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the nanom||mUon doho applicable to the Policy. F. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(m) or organization(s) named in the Schedule in the event of m pending cancellation of coverage. We have no legal ohUQmdon of any kind to any such person(s) or m,ganizmdun(a). Our failure to provide advance nmUfiooUon of cancellation to the pwroom(m) mrnrgmnizoUnn(m) shown in the Schedule nhmU impose no obligation or liability of any kind upon us, ourogent orrepresentatives, will not extend any Policy cancellation date and will not negate any cancellation ofthe Policy. G. We are not responsible fp/wehfyin0 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 ,apnmomnboUve does not pnw|dm us with mSchedule,wmhave noresponsibility for taking action under this endorsement. |naddition,ifneither you nor your representative provides un with e-mail and phyo|un| address information with respect to m particular person or organization, then we shall have no responsibility for taking action with regard to such person or entity under this endorsement. H. We may arrange with your representative to mend such notice in the event ofany such cancellation. U. You will cooperate with us in providing the Sohedu|m,or in causing your representative to provide the Schedule. J. This endorsement does not apply inthe event that you cancel the Policy. ALL-32687(05/11) Page 1 of 2 All other terms and conditions of the Policy remain unchanged. Authorized Representative ALL-32687(05111) Page 2 of 2 Workers'Compensation and Employers' ,lability Policy Named Insured Endorsement Number Nestle Waters North America Holdings, Inc. Policy Number Symbol: WLR Number:064626188 Policy Period Effective Date of Endorsement 1/1/2018 TO 1/1/2019 ACE American Insurance Cols ) lssucd Ily(Name of losmance Cor Company i Inset the polio number.The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the olicy. 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: 3. Premium: The premium charge for this endorsement shall be 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 : Aualmimd Agog WC 99 03 22