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xym <br /> rc RCERTIFIGtTE OF LIABILITY 1 oPID cl DATE""Do o <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($),AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. <br /> I P R A e certificate holder Is an po Cy must bi endorsed. ,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 NAME. <br /> George Petersen Ins Agency PHONE <br /> P. 0. Box 3539 AC,No,Ext_)__---------_—.__-- tA!c.No)_— --- <br /> 627 College Avenue ADDRESS: <br /> DUC <br /> Santa Ross CA 95402 CUSTOMER IDA SERVI01 _ ---------_---_ — <br /> Phone:707-525-4150 Fax:707-525-4175 INSURER(S)AFFORDING COVERAGE NAIC0 <br /> INSURED INSURER A: Cypress Insurance COm ani+ <br /> Se4,vice Station Systems, Inc. INSURER 8: <br /> 680 Quinn Avenue - <br /> San Jose CA 95112 INSURER C., <br /> INSURER D: <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 /> Lag POLICY OFF X�x TYPE OF INSURANCE WSR ADM'NNBD��. POLICY NUMBER (M WDDIYYYY)I(M WDDlYYYY) LIMITS <br /> GENERAL LIABILITY I EACH OCCURRENCE $ <br /> COMMERCIAL GENERAL LIABILITY PREMISES @Ea oaxxrence $ <br /> CLAIMS-MADE F OCCUR I MED EXP(Any one person) $ <br /> 111 I PERSONAL&ADV INJURY $ <br /> -- I GENERAL.AGGREGATE is <br /> GEWL AGGREGATE'LIMITAPPLIES PER: I PRODUCTS-COMPIOP AGG !!!$ <br /> POLICY PR OT- r�LOC $_.�_....�..- <br /> AUTOMOBIL.E LIABILITY COMBINED SINGLE LIMIT <br /> I (Es acciderN) $ <br /> ANY AUTO BODILY INJURY(Per person) E R <br /> ALL OWNED AUTOSI ---- -------- - <br /> .BODILY INJURY(Per acddeM) $ <br /> SCHEDULED AUTOS PROPERTY DAMAGE <br /> $ <br /> HIRED AUTOS <br /> (Per accident) <br /> NON-OWNED AUTOS I $ <br /> S <br /> UMBRELLA LIAR OCCUR EACH OCCURRENCE Is <br /> EXCESS LIAS CLAIMS MADE } AGGREGATE $ —y <br /> DEDUCTIBLE <br /> RETENTON $ Sl is <br /> A WORKER9l�MPENNUkTiON 10 3 l0i 06/04/1006/04/1 X : <br /> AND EMIPLOYERV LIABILITY YINTORY LIMITS ER < <br /> ANY PROPRIETORMARTNERIEXECU :] f E.L.EACH ACCIDENT !S1000000 <br /> OFFiCERIMEMSEREXCLUDED? IA <br /> (Mandatory In NH) EX..DISEASE-EAEMPLO —$1000000 <br /> ff I <br /> DESCR OdewONNOFOPERATIONSWow I E.L.DISEASE-POLICY LIMIT I 51000000 <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD lot,Additional Remarks Schedule,N Moro apace Is required) <br /> Proof of coverage <br /> CERTIFICATE HOLDER CANCELLATION <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 /> Proof of Coverage <br /> 0 1988-2609 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD <br />