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<br /> ,4�oi2v CERTIFICATE OF LIABILITY INSURANCE DAT111 /2DIY
<br /> 1 711 /21
<br /> 021
<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 poilcy(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 C TCT
<br /> Butte OfficePHONE FAX
<br /> PayneWest Insurance, a Marsh McLennan Agency LLC Company Arc, No, FA): (406) 494-8000 (Aro, No):(406) 494-7641
<br /> PO Box 3089 E• IL
<br /> Butte, MT 69702
<br /> INSURERS AFFORDING COVERAGE NAIC k
<br /> INSURER A . Westchester Surplus Lines Insurance Co 10172
<br /> INSURED NweINSURERS : Liberty Mutual Insurance Company 23043
<br /> ANC Vehicle Wash, Petrol Services o LLC Northwest Fuel Systems, INSURER C : Ohio Casual Insurance Company 24074
<br /> ANC V
<br /> 115 Industrial Court INSURER D : Evanston Insurance Company35378
<br /> Kalispell, MT 69901 INSURER E :
<br /> INSURER P :
<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 /> INSR TYPE OF INSURANCE IADDLNSD Wvo SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS
<br /> A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 21000,000
<br /> CLAIMS-MADE FX ] OCCUR G28147645 003 9/3012020 9130/2022 DAMAGE TO RENSESTEDmncq) S 250,000
<br /> MEDEXP (Any onePerson) S 51000
<br /> PERSONAL & ADVINJURY S 21000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: 2,000,000
<br /> POLICY � PECT 7 LOC GENERAL AGGREGATE $ 2o0001000
<br /> J PRODUCTS - COMPlOPAGG 5 '
<br /> OTHER:
<br /> $
<br /> 13 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 11000, 000
<br /> ANY AUTO BAW57384241 10/30/2021 10/3012022 BODILY INJURY Perperson) S
<br /> AUTEO��SDONLY X 71 AUUTNOSSyU�L.�EEDp BODILY INJURY Per accident S
<br /> A6RTOS ONLY AUTOS ONLY Pe�erEr1Rt AMAGE S
<br /> 5
<br /> A UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 4, 000,000
<br /> X EXCESS LIAB CLAIMS-MADE 628147557 006 9/30/2021 9/3012022 AGGREGATE
<br /> DED RETENTIONS Aggregate $ 41000,000
<br /> C WORKERS COMPENSATION PERTUTE I I OTH-
<br /> AND EMPLOYERS LIABILITY XWS57384241 10/30/2021 10/30/2022 11000,000
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L. EACH ACCIDENT ,$,,,,•,_-
<br /> SFFICERIMEM6T) EXCLUDED? N / A
<br /> Ylandatory in NH) E.L. DISEASE - EA EMPLOYE ,,$ 110001000
<br /> If yes, describe under —
<br /> DESCRIPTION OF OPERATIONS below1 ,000,000
<br /> E.L. DISEASE - POUCYLIMIT 5
<br /> D Commercial Excess Li MKLV2EFX100575 9130/2021 913012022 Excess Liability 21000,000
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101 , Additional Remarks Schedule, may be attached it more space Is required)
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> To Whom It May Concern THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> AUTHORIZED REPRESENTATIVE
<br /> ACORD 25 (2016103) O 1988-2015 ACORD CORPORATION. All rights reserved.
<br /> The ACORD name and logo are registered marks of ACORD
<br />
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