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0 SERVl01 OP ID: Cl <br />IAC- "M"DATE <br />CERTIFICATE OF LIABILITY INSURANCE <br />(MMIDDiYYYY) <br />�-� <br />D6103011 <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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder In Ileu of such endorsement(s). <br />PRODUCER 707-5254150 <br />George Petersen Ins Agency <br />P. O. Box 3839 707-525-4175 <br />62T College Avenue <br />Santa Rosa, CA 95402 <br />Douglas Dilley <br />CONTACT <br />NAME: - - <br />- -- _-�- <br />PHONE <br />No): <br />MAIL <br />ADDRESS. <br />INSURERS AFFORDINDCOVERAGE <br />-- <br />_NA1Ca <br />INSURER A: Travelers Prop Cas of America _ <br />INSURER B: <br />— <br />25674 <br />— <br />INSURED Service Station Systems, Inc. <br />3224 Regional Parkway <br />Santa Rosa, CA 95403 <br />— -- — <br />UISURERC: <br />- — <br />- — <br />JNSIIRER <br />C_OMMERCIAt GENERAL LIABILITY <br />C0VMS4AADE D OCCUR <br />INSURER E: <br />_ <br />INSURER F ; <br />-1--- <br />MED EXP (Anyone person) S <br />COVERAGES CERTIFICATE MI]MRFR- nevrelnkr Ll &110=0. <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 />1NSR I TYPE OF INSURANCE ADbR POLICY NUMBER MPOLICY EFFMJDDlYY' F- MIWDD EXP <br />rrn LIMITS <br />GENERAL LIABILITY <br />Proof of Coverage <br />ACCORDANCE WITH THE POLICY P ROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />— <br />EACH OCCURRENCE S <br />C_OMMERCIAt GENERAL LIABILITY <br />C0VMS4AADE D OCCUR <br />pRENISES (Ea obwrrenceS_- <br />-1--- <br />MED EXP (Anyone person) S <br />PERSONAL 8 ADV INJURY 3 <br />--- <br />i <br />-- <br />- <br />GENERALAGGREGATE $__. <br />i <br />GE N'L AGGREGATE LIMIT APPLIES PER: <br />PRO. LOC <br />POLICY JECI F] <br />—_ <br />PRODUCTS - COM PfOP AGG 5 <br />S <br />AUTOMOBILE <br />LIABILITY <br />I <br />GOMBIKID SINGLE LIMIT <br />BODILY INJURYPer <br />( Parson) S <br />ANY AUTO <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />— — <br />BODILY INJURY (Per ecddenl) S <br />RIREDAUTOS AUTONON-S <br />ROPER DAMA S <br />S <br />r <br />— <br />UMBRELLA LIAR <br />OCCUR <br />EACH OCCURRENCE $ <br />- <br />EXCESS UAB _ <br />�� CLAIMS -MADE <br />- --- -�-- <br />AGGREGATE f <br />DED RETENTIONS <br />$ - <br />A <br />I <br />I <br />WORXERS COUPENSATION <br />AND EMPLOYERS' LIA8IUTY <br />ANY PROPRIETOFWARTNEPJEXECUTiVE YIN <br />OFFIC'ERIMEIMBER EXCLUDED? ❑ <br />(Mandatory In NH) <br />N yes. desv3be under <br />N I A <br />UBB054F2133 <br />06104111 <br />06/04/12 <br />WC 5TATU- DTH. <br />X <br />rr,L.EACH ACCIDENT b 1,000,00 <br />F. L. DISEASE - EA EMPLOYEE i 1,000,00 <br />E. L. DISFASE - POLICY LIMB S 1,000,00 <br />DESCRIPTION OF OPERATIONS below <br />f <br />iPTIQN OF OPERAIJUNS I LOCATIONS I VEHICLES (Attach ACORD 161, Additional Remarks Schedule, H more space Is required) <br />of Coverage. <br />CERTIFICATE HOLDER CANCELLATION <br />ATION <br />©1988-2010 ACORD CORPORATION. All rights reserved. <br />ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN <br />Proof of Coverage <br />ACCORDANCE WITH THE POLICY P ROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />©1988-2010 ACORD CORPORATION. All rights reserved. <br />ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD <br />