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CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
<br /> 04/10/2025
<br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
<br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 13Y THE POLICIES
<br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
<br /> IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
<br /> If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br /> PRODUCER CONTACT M
<br /> NAME: axwell Brenner
<br /> With Coverage Insurance Services LLC PHONE FAX
<br /> AIC No);
<br /> 1440 W.Taylor St#6$9 AIL
<br /> ADDRE . team@withcoverage.corn
<br /> Chicago, IL 60607 INSURERS AFFORDING COVERAGE NAIC B
<br /> INSURERA: Travelers Property Casualty Company of America 25674
<br /> INSURED INSURER B: The Travelers Indemnity Company of Connecticut 25682
<br /> Romaine Empire,Inc.dba Farmer's Fridge INSURER C: The Travelers Indemnity Company 25658
<br /> 2000 W Fulton St INSURER D: Palomar Excess and Surplus Insurance Co 16754
<br /> Ste F310 INSURER E:
<br /> Chicago IL 60612 INSURERF:
<br /> COVERAGES CERTIFICATE NUMBER: 168248 REVISION NUMBER:001
<br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br /> INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br /> INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP
<br /> LTR POLICY NUMBER MWDD MMIDDJYYYY LIMITS
<br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br /> CLAIMS-MADE ®OCCUR U A E TO RENTED 3DO,OOD
<br /> PREMISES Ea occurrence $
<br /> MED EXP(Any ore person) $ 5,000
<br /> A X X 630-5S978173 10/12/2024 10/12/2025 PERSONAL&ADV INJURY $ 1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER! GENERAL AGGREGATE $ 2,000,000
<br /> POLICY El
<br /> PRO-
<br /> JECT LOC PRODUCTS-COMP/op AGG $ 2,000,000
<br /> OTHER: $
<br /> AUTOMOBILE LIABILITY COMM*N n SINGLE LIMIT
<br /> Ea accident $ 1,444,044
<br /> ANY AUTO BODILY INJURY(Per person) $
<br /> B SCHEDULED AUTOS X X 810-A0410266-24-14-G 10/1212024 10/1212025 BODILY INJURY(Per accident $
<br /> AUTOS ONLY AUTOS )
<br /> HIRED NON-OWNED PROPERTY DAMAGE
<br /> AUTOS ONLY AUTOS ONLY Per arxidenl $
<br /> UMBRELLALIAB OCCUR EACH OCCURRENCE $ 10,000,000
<br /> A EXCESS LIAB CLAIMS-MADE X X CUP-A0926664-24-14 10/12/2024 10/12/2026 AGGREGATE $ 10,000,000
<br /> DIED RETENTION$ $
<br /> WORKERS COMPENSATION I OTH-
<br /> AND EMPLOYERS'LIABILITY YIN STATUTE ER
<br /> C ON ICERMEMBEREXCLUDED7ECUTIVE � NIA X UB-A0402383-24.14-G 10/12/2024 10/12/2025 E•L.EACH ACCIDENT $ 1,000,000
<br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
<br /> It yes,describe under
<br /> DESCRIPTION OF OPERATIONS below E,L,DISEASE-POLICY LIMIT $ 1,000,000
<br /> Cyber-Network&Security& Aggregate $2,000,0-00
<br /> D Privacy liability PLM-CB-S3JZRHGKM-003 10/12/2024 10/12/2025 Each Claim $2,000,000
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required)
<br /> City of Santa Ana,its City Council,its Officers,officials,employees,agents,and volunteers are to be covered as additional insureds with respect to liability
<br /> arising out of work or operations performed by or on behalf of the Permittee including materials,parts,equipment,and personnel furnished in connection with
<br /> such work or operations.Insurance company agrees to waive all rights of subrogation against City,its City Council,its officers,officials,employees,agents,and
<br /> volunteers for losses paid under the terms of any policy which arise from work performed by Permittee for City. For any claims related to this contract,
<br /> Permittee's insurance coverage shall be primary and any insurance maintained by City,its City Council,its officers,officials,employees,agents,or volunteers
<br /> shall not contribute with it.A thirty(30)day written notice of cancellation(10 days for nonpayment of premium)will be provided to the Certificate Holder.
<br /> CERTIFICATE HOLDER -APPROVED-..-.. CANCELLATION
<br /> w9usor By Tu Tran Nguyen.at 2 d6 pJr Apr 14 2025"
<br /> u Tra Uye w:—y� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> 9uYe ,JK„ THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> 14Ao6:5' City of Santa Alfa ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Attention:Facilities Manager,Public Works Agency AUTHORIZED REPRESENTATIVE
<br /> 20 Civic Center Plaza,M-21
<br /> Santa Ana CA 92701
<br /> ©1988-2015 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
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