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SERVSTA -CL DWATTS <br /> DATE (MM/DD/VYYY) <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 INSUFtER(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 provis ions or be endorsed . <br /> If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy , certain policies may require an endorselrnent. A statement on <br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br /> CRATE CT <br /> PRODUCERFAX <br /> Georgge Petersen Insurance Agency, Inc. (A/cPHONENa, Ext): ( 707) 525-4150 � <br /> (A/C, , e),(707 ) 5254175 <br /> P .O. Bo% 3539 , <br /> Santa Rosa , CA 95402 AIL . info gpins .com <br /> INSURER(S) AFFORDING COVERAGE NAIC p <br /> INSURER A : Oreon Mutual Insurance Company 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 FCR 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 pOLJCY EFF POLICY EXP LIMITS <br /> LTR TYPE OF INSURANCE <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S <br /> DAMAGE TO RENTED $ <br /> CLAIMS -MADE OCCUR PREMISES (Ep <br /> MED EXP (Any one person) $ <br /> PERSONAL 8 ADV INJURY $ <br /> GENERAL AGGREGATE $ <br /> GENT AGGREGATE LIMIT APPLIES PER: <br /> POLICY ❑ jECQT LOC PRODUCTS - COMP/OP AGG <br /> $ <br /> OTHER: COMBINED SINGLE LIMIT 10000 , 000 <br /> A AUTOMOBILE LIABILITY Ea cadent <br /> X ANY AUTO CM0923523 11 /15/2021 11 /15/2022 BODILY INJURY Perperson ) $ <br /> OWNED SCHEDULED BODILY INJURY Per accident b <br /> AURRTEEOS ONLY AUTOS <br /> y.q�E (AOacEcRident AMAGE $ <br /> X AUTO ONLY AUTOS ONLDY <br /> $ <br /> UMBRELLA LIAR OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION $ PER OTH . <br /> B WORKERS COMPENSATION STATUTE ER <br /> AND EMPLOYERS' LIABILITY Y / y 046603 6/4/2022 6/4/20231 '0001000 <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E. L. EACH ACCIDENT $ <br /> NIA FICER/MEMggER EXCLUDED? 1 ,000 , 000 <br /> Wendatory In NH) E . L. DISEASE - EA EMPLOYEE $ <br /> If yes, describe under E . L. DISEASE - POLICY LIMIT $ 110001000 <br /> DESCRIPTION OF OPERATIONS below <br /> DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101 , Additional Remarks Schedule , may be attached H more space In 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 /> 1 ll Y . <br /> ACORD 25 ( 2016/03 ) � \ © 1988 -2015 ACORD CORPORATION . All rights reserved . <br /> The ACORD name and logo are registered marks of ACORD <br />