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SERVSTA -CL DWATTS <br /> DATE (MM/DD/YYYY) <br /> CERTIFICATE OF LIABILITY INSURANCE 6/1 /2022 <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(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 endorSGment. A statement on <br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br /> C TACT <br /> PRODUCER FAX (707 ) 525175 <br /> George Petersen Insurance Agency , Inc. PHONE 525 -4150 NCC, Ivo): <br /> P . O. Box 3539 (A/c , IL Ext): (707 ) <br /> Santa Rosa , CA 95402 AIL . info gpins .com <br /> INSURERS AFFORDING COVERAGE NAIC q <br /> INSURER A : Oregon Mutual Insurance Comp ny 14907 <br /> INSURED INSURER B : WCF National Insurance Company <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. 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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS <br /> TYPE OF INSURANCE <br /> LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ '.. <br /> DAMAGE TO RENTED <br /> CLAIMS-MADE OCCUR P o b <br /> MED EXP (Any oneperson) $ '... <br /> PERSONAL 8 ADV INJURY $ '.. <br /> GENERAL AGGREGATE $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER: '.. <br /> POLICY a jRej LOC PRODUCTS - COMP/OP AGG <br /> S <br /> OTHER: COMBINED SINGLE LIMIT 190()01000 <br /> A AUTOMOBILE LIABILITY Ea acriderin ±; <br /> X ANY AUTO CM0923523 11 /15/2021 11 /15/2022 BODILY INJURY Perperson) b <br /> OWNED SCHEDULED BODILY INJURY Per accident s <br /> AUTOS ONLY AUUTOSSW JE PPIOPERidenl AMAGE $ <br /> X AUTODS ONLY X AUTOS ONLDY <br /> 5 <br /> UMBRELLA LIAR =OCCUREACH OCCURRENCE $ <br /> EXCESS LIAB AGGREGATE S <br /> DED RETENTIONS PER OTH- <br /> Et WORKERS COMPENSATION X <br /> AND EMPLOYERS' LIABILITY YIN 4046603 6/4/2022 6/4/2023E. L. EACH ACCIDENT $ 110009000 <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ <br /> N / A <br /> oFFICER/MEMBEREXCLUDED9 1 ,® 00 ' 000 <br /> (Mandatoryin NH) E. L. DISEASE - EA EMPLOYEE S <br /> If yes, describe under E. L. DISEASE - POLICY LIMIT $ 1 '000 ' 000 <br /> DESCRIPTION OF OPERATIONS below <br /> DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101 , Additional Remarks Schedule , may be attached If more apace 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 /> ACCORDANCE WITH THE POLICY PROVISIONS . <br /> AUTHORIZED REPRESENTATIVE <br /> © 1988 -2015 ACORD CORPORATION . All rights reserved . <br /> ACORD 25 ( 2016/03 ) <br /> i <br /> The ACORD name and logo are registered marks of ACORD <br /> E <br />