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HomeMy WebLinkAbout498989 XYLEM WATER SOLUTIONS USA INC - INSURANCE CERTIFICATE (2)ACO®® DATE(MMIDDmtiv) � CERTIFICATE OF LIABILITY INSURANCE 1or3tnols 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 endonsement(s). PRODUCER CONTACT Lauren Giangrande - Marsh USA, Inc. PHONE (212) 345 6000 FAX 1166 Avenue of the Americas A/C No): New York, NY 10036 E_ �1 miranr;iarinnmdardlm mi, rnm INSURED Xylem Water Solutions USA, Inc. Leopold Prodtids 227 S. Division St. Zekenople, PA 16063 19445 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERMIOR CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS; MAY HAVE BEEN REDUCED BY PAID CLAIMS. �TR TYPE OF INSURANCE _ UB POLICY NUMBER MMUD� M UD/YYY UMTS B X CoumERCULGENERALuaeluTY CLAIMS -MADE MX OCCUR GL6869% 10/31/2019 1013112020 EACH OCCURRENCE $ 1,000,000 DAMAGE TO PREMISES Ea occurce- $ 1,000,000 MEDEXP one on .$ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY1:1 PRO- JECT M LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 SIR:11,000,000 $ B B B AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY CA 5320316 CA 5320317 CA 5320318 (AOS) 1 (VA) (MA) 10/3112019 10/3112019 10/31/2019 10/3V2020 10/3112020 10131)2020 COMBINED SINGLE LIMIT Ea acciderd $ 3.,000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) - $ PROPERTY DAMAGE Per accident $ UMBRELLAUA EXCESS Like OCCUR CLAIMS -MADE � _ EACH. OCCURRENCE $ AGGREGATE $ DED RETENTION$ $. A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY y I N ANYPROPRIETOR/PARTNER/EXECUTIVE EXCLUDED? F_N1 (Mandatory In NH) If yes describe raider DESCRIPTION OF OPERATIONS below NIA SEE ACORD 101 _ 1 X PER 0TH= -STATUTE ER - - - - - E.L. EACH ACCIDENT $. ZOOMOFFICER/MEMBER E.L. DISEASE.- EA EMPLOYEE $ 2,000,000 .E.L. DISEASE .-POLICY-LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional City of Fort Collins is included as additional insured (except Workers Compensations Remarks Schedule, may be attsched N more space Is required) as required by written contract. City of Fort Collins SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 215 N Mason St, 2nd Floor THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 580 ACCORDANCE WITH THE POLICY PROVISIONS. Fort Collins, CO 80522 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Lauren Giagrandeo, dy 01988-2016 ACORD CORPORATION. All rights reserved. ACORD 26 (2016/63) The ACORD Lame and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN108453421 LOC #: New York ACR !P ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA, Inc. I Xylem Water Solutions USA, Inc. - Leopold Products 227 S. Division St. POLICY NUMBER - Zelienople, PA 16063 CARRIER I NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:. 25 FORM TITLE: Certificate of Liability Insul WORKERS COMPENSATION: CARRIER NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608516 (AOS) CARRIER: NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608517 (IL, KY, NC, NH, UT, VT) CARRIER NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608518 (NJ, PA) CARRIER: NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608519 (MA, OH, WA, WI, WY) CARRIER: AMERICAN HOME ASSURANCE POLICY: WC 020608620 (CA) CARRIER ILLINOIS NATIONAL INSURANCE COMPANY POLICY: WC 020608521 (FL) CARRIER: NEW HAMPSHIRE INSURANCE COMPANY POLICY: WC 020608M (AZ, VA) ACORD 101 (2408101) I © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD