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1 SERVSTA -CL CMEES1 <br /> CERTIFICATE F LIABILITY INSURANCE RA DATE (MMIDDIYYYY) <br /> I <br /> 5/29/2019 <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 /> IMPORT11 ANT : if the certificate holder Is an ADDITIONAL INSURED, the policy( ies ) must have ADDITIONAL INSURED provisions or be endorsed . <br /> If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy , certain policies may require an endorsement. A statement on <br /> this certificate does not confer rights to the certificate holder In lieu of such endorsement(s ). <br /> PRODUCER License V 0603247 - CONTACT <br /> AME <br /> Geor a Petersen Insurance Agency, Inc. PHONE 707 5254150 <br /> g (AIC, E Ext): ( ) (A1C, No): (707) 525 -4175 <br /> P .O . Box 3539 ADDRIES : info gpins . com <br /> Santa Rosa , CA 95402 <br /> INSURERS AFFORDING COVERAGE NAIC # <br /> INSURER A : Insurance Com an of the West 27847 <br /> INSURED INSURER B : <br /> Service Station Systems , Inc. INSURER C : <br /> 3224 Regional Parkway INSURER D : <br /> Santa Rosa , CA 95403 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, NOTVVITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br /> j 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS <br /> TYPE OF INSURANCE g p POLICY NUMBER Ip <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br /> DAMAGE TO RENTED <br /> CLAIMS-MADE OCCUR PREMISES Ea occurrence $ <br /> MED EXP (Any oneperson) $ <br /> PERSONAL & ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> POLICY ❑ PRO F-1 LOC PRODUCTS - COMP/OP AGG $ <br /> JECT <br /> OTHER: $ <br /> C a eBBINEDISINGLE LIMIT $ <br /> AUTOMOBILE LIABILITY -- <br /> ANY AUTO BODILY INJURY Perperson) $„•_ <br /> AOURTEOSDONLY AUOTOpSWULNEEDp BOODILY INJURY Per accident $ _ <br /> AUTOS ONLY AUTOS ONLY PPerr acc dent AMAGE $ <br /> $ <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION $ $ <br /> A WORKERS COMPENSATION X PTR U ER <br /> OTH- <br /> AND EMPLOYERS' LIABILITY YIN WPL 5021307 07 6/4/20196/4/2020 110000000 <br /> I ANY PROPRIETORIPARTNER/EXECUTIVE ❑ NIA A E.L. EACH ACCIDENT $ <br />(, 0FFICERIMEMggER EXCLUDED? E.L. DISEASE - EA EMPLOYE 120001000 <br /> (Mandatory In NH) .. <br /> It DESCRIPTION descdbe un OPERATIONS below der E.L. DISEASE - POLICY LIMIT $ 1 , 0000000 <br /> i <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101 , Additional Remarks Schedule, may be attached If more space is required) <br /> RE : 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 /> Proof of Coverage ACCORDANCE WITH THE POLICY PROVISIONS . <br /> AUTHORIZED REPRESENTATIVE <br /> ACORD 25 ( 2016/03) © 19884015 ACORD CORPORATION . All rights reserved . <br /> The ACORD name and logo are registered marks of ACORD <br />