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710/16/2025
<br /> E(MM/DD/YYYY)
<br /> ACOR" CERTIFICATE OF LIABILITY INSURANCE
<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 CONTACT Maxwell Brenner
<br /> NAME:
<br /> E FAX
<br /> With Coverage Insurance Services LLC A CC No Ext: A/C,No):
<br /> 1440 W.Taylor St#689 E-MADDRESS: team@withcoverage.com
<br /> Chicago, IL60607 INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURERA: Travelers Property Casualty Company of America 25674
<br /> INSURED INSURERB: Palomar Excess and Surplus Insurance Co 16754
<br /> Romaine Empire, Inc.dba Farmer's Fridge INSURERC:
<br /> 2000 W Fulton St INSURER D:
<br /> Ste F310 INSURER E:
<br /> Chicago IL 60612 INSURERF:
<br /> COVERAGES CERTIFICATE NUMBER: 925278 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 /> INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
<br /> LTR INSD WVD POLICYNUMBER MM/DD MM/DD
<br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br /> CLAIMS-MADE RENTE
<br /> ® OCCUR 'REM SES(DAMAGE ToE.occur ence) $ 300,000
<br /> MED EXP(Any one person) $ 5,000
<br /> A X X Y-630-5S978173-TIL-25 10/12/2025 10/12/2026 PERSONAL&ADV INJURY $ 1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000
<br /> POLICY PRO-
<br /> JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000
<br /> OTHER: $
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
<br /> Ea accident $ 1,000,000
<br /> ANY AUTO BODILY INJURY(Per person) $
<br /> A OWNED SCHEDULED X X 810-A0410266-25-14-G 10/12/2025 10/12/2026 BODILY INJURY(Per accident) $
<br /> AUTOS ONLY AUTOS
<br /> HIRED NON-OWNED PROPERTY DAMAGE $
<br /> AUTOS ONLY AUTOS ONLY Per accident
<br /> UMBRELLA LAB OCCUR EACH OCCURRENCE $ 10,000,000
<br /> A EXCESS LAB CLAIMS-MADE X X CUP-A0926664-25-14 10/12/2025 10/12/2026 AGGREGATE $ 10,000,000
<br /> DED RETENTION$ $
<br /> WORKERS COMPENSATION PER OTH-
<br /> AND EMPLOYERS'LIABILITY Y/N STATUTE ER
<br /> ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000
<br /> A OFFICER/MEMBEREXCLUDED? āN N/A X UB-A0402383-25-14-G 10/12/2025 10/12/2026
<br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
<br /> Cyber-Network&Security& Aggregate $2,000,000
<br /> B Privacy Liability PLM-CB-S3JZRHGKM-004 10/12/2025 10/12/2026 Each Claim $2,000,000
<br /> DESCRIPTION OF OPERATIONS/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 /> By Tu Tran Nguyen at 7:24 am,Nov 04,2025
<br /> D,g,tAy,,gād SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> TU Train byr THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> Nqu'e
<br /> City Of Santa Ana Nguyen oaie:zoz5.,,.oa ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> 072505 0800'
<br /> Attention: Facilities Manager, Public Works Agency
<br /> AUTHORIZED REPRESENTATIVE
<br /> 20 Civic Center Plaza, M-21
<br /> Santa Ana CA 92701 'I
<br /> @ 1988-2015 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
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