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PROOF OF INSURANCE (2020) CLOSED s 0 DATE(MMIDDIYYYY) ACC7hd"" CERTIFICATE OF LIABILITY INSURANCE ( 0310512019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS u 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 501arsh Me Merritt 7 FAX ,Inc. (Alr RN s xt), _ Norwalk,CT 06856-0770 E-MAIL INSURER(S)AFFORDING COVERAGE NAIC# V CN I 02013285-NW-GAW-1 9-20 X Medina INSURER A. _ ACE American Insurance Company �22667 INSURED R H AMERICA HOLDINGS INC INSURER®,; demnity Ins Co Of North America 43575 NESTLE WATERS REA YREFRESH BYO ONESTLE INSURER C ACE Fire Underwriters Insurance Com a �. . P E --- --— ......... .20702- ------- ATTN: RISK MANAGEMENT INSURER D: 1812 N.MOORE STREET,STE 3500 ARLINGTON,VA 22209 I INSURER E: INSURER F; COVERAGES CERTIFICATE NUMBER: NYC-009682252-09 REVISION NUMBER: 9 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. INSI2 .... .... ...., ADDLSU rPOLICYM'YYYI dMMCICtiE TYPE OF INSURANCE POLICY NUMBER POLICY EFF PML XP LIMITS LTR� �! '' DDdYYYYN V A X COMMERCIAL GENERAL LIABILITY HDOG71234204 01101/2019 01/01/2020 EACH OCCURRENCE $ 2,000,000 DAMAGE'1'O NRENTED.... — 1,000,000 CLAIMS-MADE ...,I X OCCUR ._ „�yaaooup $ 00) .PRFMIS S Erren,ce $ MED EXP(An one arson) 10 0 PERSONAL&ADV INJURY $ 2,000,000 G'E.WL AGGREGATE LIMIT APPLIES PER: GENERAL AG,GR,E,GATE $ 5,000,000 ....X.,,1 POLICY F7 PRO LOC 5,000,000 JEC'T ,,,,........,..COMP/OP AGG $ PRODUCTS- ............. ..... -- - OTHER,. .. $ A AUTOMOBILE LIABILITY ISA H25278318(AOS) 01/01/2019 01/01/2020 COMBINED SINGLE LIMIT' $ 2,000,000 LEa„ORP4v C) — A X ANYAUTO ISA H25278392(NEW HAMPSHIRE) 01101/2019 01/01/2020 BODILY INJURY(Per person) $ A .,, J AUTOS ONLY AUTOS ONLY _{ ps PEida DAMAGE accident) $ CT,FL,IL,KS,LA,NY,OK,VT,VA 1 { ( ) PR ------ . .. PR<.TPer�1v P0� $ HIRED NON-OWNED rot OWNED SCHEDULED ISA H25278355 BODILY IN — $ 11 UMBRELLA LIABI OCCUR EACH OCCURRENCE EXCESS LIAB —CLAIMS-MADE AGGREGATE ($,,,,,,,,,,,,,,,,,,,,,,,,,, DED B WORKER'S COM IEON$ SATIO C S) 01/0112019 01/01/2020 X PER AND EMPLOYERS'LIABILITY 2019 01/01/2020 -STATUTE A ANYP O RIET ��A CINE EXEC'UTNvc YIN NIA WLR 065433618(A�CA&MA) 01I01�2019 01/01/2020 EJ_ EACH ACCIDENT ERH $,,, 1,000,000 MPL (Mandato If rs,describe e un OPERATIONS�IDeldwr,' Y LIMIT $ 00 0 C SCF 065433655 WI E.L.DISEASE-Pouc 1,0 JPT (y NH) E L DISEASE-EA E $ 00 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 EI 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. EI Segundo,CA 90245 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee �toLuao� - ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 4 POLICY NUMBER: HDO G71234204 Endorsement Number: 3 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHT'S OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: 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 Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products- completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 ©Insurance Services Office, Inc., 2008 Page 1 of 1 3 NOTICE TO OTHERS ENDORSEMENT -SCHEDULE Named Insured Nestle Waters North America Holdings, Inc. Endorsement Number 5 Policy Symbol I Policy Number Policy Period Effective Date of Endorsement H DO IG71234204 01/0112019 TO 01/01/2020 Issued By(Name of Insurance Company) ACE American Insurance Company hisert the polloy number,The rems0der of the Informatimi is to be completed only when this endorsement is Ismxd sw.uhsequent in the preparation of the pollcy. 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 notification as we determine, to the persons or organizations listed in the schedule that you or your representative provide or have provided to us (the "Schedule"). 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. B. The Schedule must be initially provided to us within 15 days 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 Policy, if this endorsement is effective after 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 cancellation is mailed or delivered to the first Named Insured. E. We will endeavor to send or deliver such notice 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 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 person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or organization(s) shown 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. G. We are not responsible for verifying 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 does not provide us with a Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail and physical address information with respect to a 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 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 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 Einployers"Liabilily 1*oiicy Named Insured Endorsement Number Nestle Waters North America Holdings, Inc. Policy Number Svmbal: WLR Number: 065433618 Policy Period Effective Date of Endorsement 1/1/2019 TO......1..11..12.D.z.0..... .. �. Issued By(Name of Insurance Company) ACE American Insurance Companv u Insert the 11,iolkv number.']"lie rennWsl&r of aha;hifrt rnikirai is to be coniMered only when an endorsement is issued subsequem to the t7reparXX11r 04 We 07wa6'CV, 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: Authorized Agent WC 99 03 22