Laserfiche WebLink
SERVSTA-01 ILICHALI <br />CERT IT OF LIABILITYIS NCE <br />DATE(MMIDD/YYYY) <br />TYPE OF INSURANCE <br />6/6/2012 <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 <br />George Petersen Insurance Agency, Inc. <br />P.O. Box 3539 <br />Santa Rosa, CA 95402 <br />' <br />NAME: <br />PHONE $00 2 FAX <br />A/C No Ext : ( ) 36-9046 X No : (888) 579-2743 <br />MAIL <br />ADDRESS: <br />INSURER(S) AFFORDING COVERAGE NAIC 0 <br />GENERAL LIABILITY <br />INSURER A: ICW Group <br />INSURED <br />INSURER B: <br />Service Station Systems, Inc. <br />INSURER C <br />680 Quinn Ave <br />San Jose, CA 95112 <br />INSURER D: <br />INSURER E <br />INSURER F: <br />------ rcctnaevK 1 UMOCK: <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 <br />LTR <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />P LICY EFF <br />IMMIDIDIYYYYI <br />POLI Y XP <br />(MM/DD/YYM <br />LIMITS <br />GENERAL LIABILITY <br />EACH OCCURRENCE $ <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE F—I OCCUR <br />DAMAGE TO RENTED <br />PREMISES Ea occurrence $ <br />MED EXP (Any one person) $ <br />PERSONAL & ADV INJURY $ <br />GENERAL AGGREGATE $ <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />POLICY PRO LOC <br />PRODUCTS - COMP/OP AGG $ <br />$ <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea accident <br />ANY AUTO <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />HIRED AUTOSNON-OWNED <br />AUTOS <br />BODILYINJURY (Per person) $ <br />BODILY INJURY (Per accident) $ <br />PROPERTY DAMAGE <br />Per accident $ <br />UMBRELLA LIAB <br />EXCESS LIAB <br />OCCUR <br />CLAIMS -MADE <br />EACH OCCURRENCE $ <br />AGGREGATE $ <br />DED RETENTION $ <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N <br />OFFICERIMEMBER EXCLUDED? <br />A <br />N / A <br />PL502130700 <br />6/4/2012 <br />6/4/2013 <br />$ <br />WC STATU• OTH- <br />X T Y I ITS ER <br />E.L. EACH ACCIDENT $ <br />IMandatoryInNH)und <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE -EA EMPLOYE $ <br />000 <br />E.L. DISEASE - POLICY LIMIT $ <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) <br />Proof of coverage <br />rrerrnnerr un. nrr. _ <br />Proof of Coverage <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />(3R• <br />W 1VOO-XU1U At;VKU GOKPORATION. All rights reserved. <br />ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD <br />