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Digitally signed by Francine R.
<br />Francine R. Villareal Villareal
<br />Date: 2021.02.01 16:01:31-08'00'
<br />AC„C) " CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (MM/DD/YYYY)
<br />1/28/2021
<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 BY 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
<br />CONTACT
<br />NAME: FirstMark Insurance Group, Inc.
<br />FirstMark Insurance Grou , Inc
<br />p
<br />PHONE 425 582-9037
<br />A/C, No, Ext : (A/C, No):
<br />ADDRESS: commercial@firstmarkinsurance.com
<br />210 S Main St, Suite 203
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A : SENTINEL INS CO LTD
<br />11000
<br />Edmonds WA 98020
<br />INSURED
<br />INSURER B :
<br />INSURER C :
<br />Bay Sprouts LLC
<br />INSURER D :
<br />11800 Foothill Blvd
<br />INSURER E :
<br />INSURER F :
<br />Sylmar CA 91342
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<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 />LTR
<br />TYPE OF INSURANCE
<br />INSD
<br />WVD
<br />POLICY NUMBER
<br />(MM/DD/YYYY)
<br />(MM/DD/YYYY)
<br />LIMITS
<br />x
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE OCCUR
<br />PREMISES (Ea occurrence)
<br />$ 1,000,000
<br />MED EXP (Any one person)
<br />$ 10,000
<br />PERSONAL a ADV INJURY
<br />$ 1,000,000
<br />A
<br />Y
<br />59SBARV9040
<br />11/13/2020
<br />11/13/2021
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />X POLICY ❑ JJECT LOC
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />HRDBB
<br />$ 1,000,000
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />(Ea accident)
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />A
<br />OWNED SCHEDULED AUTOS ONLY AUTOS
<br />59SBARV9040
<br />11/13/2020
<br />11/13/2021
<br />BODILY INJURY (Per accident)
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY /� AUTOS ONLY
<br />��//
<br />/C
<br />(Per accident)
<br />$
<br />x
<br />UMBRELLA LAB
<br />x
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 6,000,000
<br />E
<br />IEXCESS
<br />LAB
<br />CLAIMS -MADE
<br />59SBARV9040
<br />11/13/2020
<br />11/13/2021
<br />AGGREGATE
<br />$ 6,000,000
<br />DED
<br />I X RETENTION $ 10,000
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />N / A
<br />59WECAC9055
<br />07/3/2020
<br />07/3/2021
<br />X STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Re: Bean Sprouts dba Bay Sprouts LLC.
<br />City of Santa Ana, Risk Management, its officers, employees, agents, representatives, and volunteers are included as Additional Insured with respect to
<br />General Liability where required by written contract. This insurance is Primary and Non -Contributory over any other insurance. 30-day written cancellation
<br />applies; 10-days in the event of non-payment of premium.
<br />CERTIFICATE HOLDER CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Risk Management Division
<br />20 Civic Center Plaza, 4th floor
<br />Santa Ana, CA 92702
<br />AUTHORIZED REPRESENTATIVE
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<br />REVIEWED & APPRovED BY.-
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<br />Wsk MPanngement Analyst
<br />© 1988-2015 ACORD
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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