HomeMy WebLinkAbout498989 XYLEM WATER SOLUTIONS USA INC - INSURANCE CERTIFICATEA��R�® CERTIFICATE OF LIABILITY INSURANCE
DATE /2018 /YYYY)
to/26/2ot6
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 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
Marsh USA, Inc.
1166 Avenue of the Americas
CONTACT
NAME:
_
PHONE FAX
A/c A/c No):
E-MAIL
ADDRESS:
New York, NY 10036
INSURERS AFFORDING COVERAGE
NAIC #
INSURER A: ACE American Insurance Company
22667
CN108453421-STNO-GAWex-18-19
INSURED
Xylem Water Solutions USA, Inc.
Leopold Products
INSURER 8 : ACE Fire Underwriters Ins. Co.
20702
INSURER C : Indemnity Insurance Company of North America
43575
INSURER D : Allianz Global Risks US Insurance Company
35300
227 South Division Street
Zelienople, PA 16063
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: NYC-010128267-10 REVISION NUMBER: 8
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
LTR
TYPE OF INSURANCE
ADDL
SUBR
POLICY NUMBER
POLICY EFF
MMlDD/YYYY
POLICY EXP
MM/DD/YYYY
LIMITS
D
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE rxl OCCUR
USLOO107118
10131/2018
10/31/2019
EACH OCCURRENCE
_15AMA
$ 1,000,000
E T RENTED
PREMISES Ea occurrence
$ 1,000,000
MED EXP (Any one person)
$ 10,000
PERSONAL & ADV INJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER.
X POLICY ❑ JECT PRO El
OTHER
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP/OP AGG
$ 2,000,000
SIR: $1,000,000
$
A
AUTOMOBILE LIABILITY
X ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
ISA H25272754
10/31/2018
10/31/2019
COMBINED SINGLE LIMIT
Ea accident
$ 3,000,000
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
$
UMBRELLA
EXCESS LIAR
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DED I I RETENTION $
$
C
B
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes describe under
DESCRIPTION OF OPERATIONS below
N / A
WLR C65437065 (AOS)
SCF C65437107 (WI)
WLR C65437028 CA, MA, OR
( )
10/31/2018
10/31I2018
1013112019
10/31/2019
10131/2019
H
X IPER STATUTE ER
'--
E.L. EACH ACCIDENT
$ 2,000,000
E.L. DISEASE - EA EMPLOYEE
$ 2,000,000
E.L. DISEASE - POLICY LIMIT
$ 2,000 000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
City of Fort Collins is included as additional insured (except Workers Compensation) as required by written contract.
City of Fort Collins
PO Box 580
Fort Collins, CO 80522
t1AI4VCLLA I IVrl
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Lauren Giagrande
V IUStf-ZUl6 At;UKU UUKNUKA I IUN. Ali rignis reserveu.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD