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,4C d SERVSTA-01 ILICHAU <br /> CERT ICATE OF LIABILITY INSURANCE I°AfiE(MMr°°lYYYY; <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE12012 <br /> 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 lieu of such endorsement(s). <br /> PRODUCER License#0603247 CONTACT <br /> George Petersen Insurance Agency,Inc. NAME: <br /> PHONE <br /> P.O. ox 3539 aIC Na E ;(800)236-9046 arc Na:(88S)579-2743 <br /> Santa Rosa,CA 95402 E-MAIL <br /> ADDRESS: <br /> INSURERS)AFFORDING COVERAGE NAIC 0 <br /> INSURER A:ICW Group <br /> INSURER @: <br /> Service Station Systems,Inc. INSURERC: <br /> 680 Quinn Ave INSURER D: <br /> San Jose,CA 95112 <br /> INSURER E: <br /> - INSURER F <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 /> TSR <br /> R I TYPE OF INSURANCE N POLICY NUMBER POLICY <br /> YlYEFFYYY PO ICY EXP <br /> YY LIMITS <br /> GENERAL LIABILITY MMIDD _ <br /> EACH OCCURRENCE $ <br /> COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ <br /> CLAIMS-MAGE OCCUR MED EXP(Any one person) $ <br /> PERSONALS ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> PRO PRODUCTS-COMP/OP AGG $ <br /> POLICY LOC <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT <br /> Es accident <br /> ALLL OWNED ANY SCHEDULEDBODILY INJURY(Per person) $ <br /> AUTOS AUTOS BODILY INJURY(Per accident) $ <br /> HIRED AUTOS NON-OWNED <br /> AUTOS PROPERTY DAMAGE $ <br /> Per accident <br /> UMBRELLA LlA@ OCCUR $ <br /> EXCESS LIA@ CLAIMS-MADE EACH OCCURRENCE $ <br /> AGGREGATE $ <br /> DED RETENTION$ - <br /> WORKERS COMPENSATION $ <br /> AND EMPLOYERS'LIABILITY XWC STATU- OTH- <br /> A ANYPROPRIETOR/PARTNERIEXECUTIVEYIN PL502130700 61412012 61412013 RY MIT ER $ 10Q4r004 <br /> OFFICER/MEMBER EXCLUDED? N!A E.L.EACH ACCIDENT <br /> (Mandatory In NH) <br /> If yes,describe under E.L.DISEASE-EA EMPLOYE $ 1,000,000 <br /> DESCRIPTION OF OPERATIONS below <br /> E.L.DISEASE-POLICY LIMIT $ 1,000,000 <br /> DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remar$s Schedule,If more space Is required) <br /> Proof of coverage <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE l <br /> Proof of Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS. JI <br /> AUTHORIZED REPRESENTATIVE <br /> (D 1988-2010 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD <br />