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• SERVSTA-01 ILICHAL <br /> A�oRa'' <br /> CERTIFICATE OF LIABILITY INSURANCE DATE(MNDDY YY) <br /> 662012 <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 lieu of such endorsement(s). <br /> PRODUCER License#0603247 NAME: <br /> P.O.George Petersen Insurance Agency,Inc. PHONE <br /> E ,(g00 236.9046 <br /> P.O.Box 3539 uc No:(888)579-2743 <br /> Santa Rosa,CA 95402 E-MAIL <br /> ADDRESS: <br /> INSURER(S AFFORDING COVERAGE NAI;a <br /> INSURED INSURER A:ICVV Group <br /> INSURER B: <br /> Service Station Systems,Inc. INSURER C: <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 /> ILTR TYPE OF INSURANCE POLICY NUMBER IWDID/YYYY MMIDDMYYY LIMITS <br /> GENERAL LIABILITY <br /> EACH OCCURRENCE $ <br /> COMMERCIAL GENERAL UABILTY <br /> PREMISES Ea MoUrrance $ <br /> CLAIMS-MADE ❑OCCUR MEDEXP(Anymommon $ <br /> PERSONAL$ADV INJURY $ <br /> GENERAL AGGREGATE It <br /> GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPX)P AGG $ <br /> POLICY PRO- LOC $ <br /> AUTOMOBILE LIABILITY CO NED SINGLE LIMI <br /> Es Drldenl <br /> ANYAUTO BODILY INJURY(Perpemen) $ <br /> ALL OWNED SCHEDULED <br /> AUTOS AUTOS BODILY INJURY(Per soddent) $ <br /> HIRED AUTOS NON-OWNED PROPERTYPIDAMAGE $ <br /> AUTOS <br /> cciden <br /> UMBRELLA LIAR OCCUR $ <br /> EACH OCCURRENCE $ <br /> EXCESS LIAR CINMS-MADE <br /> AGGREGATE $ <br /> DED RETENTION$ $ <br /> WORKERS COMPENSATIONRS'LIILIT V/C STATU- OTH. <br /> AND EMPLOYERS'LIABILITY X <br /> A ONY FFICER EMBER EXCLUDED? <br /> YIN PL502130700 6/412012 61412013 E.L.EACH ACCIDENT $ 1,000,000 <br /> (ManOFFlCERARIatory n NH) <br /> EXCLUDEOT N/A <br /> ffws,describe <br /> and E.L DISEASE-EA EMPLOYE $ 1,000,000 <br /> S yes eesalEa under <br /> DESCRIPTION OF OPERATIONS MIM EL.DISEASE-POLICY UMIT $ 1.000,000 <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Aaech ACORD 101,AedRlonal Remarks Schedule,X more space is required) <br /> Proof of coverage <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Proof Of Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> AUT1/H/O(11JJRI/yZIED(\REPRESENTATIVE <br /> 01988.2010 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD <br />