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Client#: 1047352 SERVISTA10 <br /> ACORD. CERTIFICATE OF LIABILITY INSURANCE E!DATE(MM/D7-- <br /> THIS <br /> 6109/20 <br /> BELOW. THIS CERTIFICATE AFFIRMATIVELYCERTIFICATE DOES NOT INSURANCE DOES NEGATIVELY <br /> AMEND, <br /> M TUTS A CONTRACT ALTER THE COVERAGE AFFORDED BY THE POLICIES <br /> 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}rnust have ADDITIONAL INSURED provisions or be endorsad, <br /> If SUBROGATION IS WAIVED, subJect to the farms and conditions of the policy, certain policies may require an endorsement. A statement on <br /> this certificate does not confer any rights to the certificate holder In lieu of such endorsement(s). <br /> PRODUCER <br /> USI Insurance Services NW CL1 P E Rhonda Scialpi <br /> _I p, o,Extl: 503 224.8390 � ���c. N1610 362-8130 <br /> 825 NE Multnomah, Suite 1500 [�oDRess• rhondascialpl@usl.com ��� <br /> Portland, OR 97232 <br /> 503 224.8390D _ INSURER(S)AFFORDING COVERAGE _ NAIC# <br /> _.._. INSURE A. Insurance Company of the West 27847 <br /> INSURE �Service Station Systems, Inc. INSURER B ---- ---- <br /> 3224 Regional Parkway INSURERC: <br /> Santa Rosa, CA 95403 INSURER 0: <br /> INSURER E: <br /> MSURER F: <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES 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 /> LTR TYPE OF INSURANCE DO L US "'p0�j 0 ----.-���AAAA - <br /> _ NSR, ylvtt _ POLICY NUMBER rMM/0DMIMMlDDnvYYj LIMITS <br /> 1 _—_ <br /> COMMERCIAL GENERAL LIABILITY - ---.—_ - <br /> -- EACH OCCURRENCE $ <br /> CLAIMS-MADE DOCCUR { PREMIlj%S F oc7wn0enrh' $ <br /> MED EXP(Any ane person) S <br /> PERSONAL&ADV INJURY IS <br /> GE_N'L AGGREGATE LIMIT APPLIES PER: ' GENERAL AGGREGATE $ <br /> PRO- ( _ <br /> POLICY JECT LOC PRODUCTS-COMPIOPAGG $ w __ <br /> OTHER <br /> _ —�.T $ <br /> AUTOMOBILE LIABILITY -00 BI SINGLET MIi^ <br /> � Ee accldant� <br /> ANY AUTO <br /> BODILY INJURY(Per Person) $ <br /> OWNED SCHEDULED <br /> AUTOS ONLY AUTOS BODILY INJURY(Paraccldent) S _ <br /> HIRED NON•OWNED <br /> AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE - <br /> rPeraxldent $ <br /> � UMBRELLA LIAB OCCUR _1 <br /> —{ EACH OCCURRENCE S <br /> EXCESS LIAB CLAIMS-MADE. AGGREGATE g <br /> DED RETENTIONS <br /> WORKERS COMPENSATION $— ----.. <br /> A WLV507821801 6/04/2025 06/04/202 X PER �?°rT"' <br /> AND EMPLOYERS, Y/N , _ <br /> ANY PROP RIETORIPARTNERlEXECUTIVE E.L.EACH $1 OOOOOO <br /> OFFICERIMEMBER EXCLUDED? a NIA <br /> ACCIDENT- <br /> (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1 000 000 Ifyes,describe under ____ <br /> _,_ DESCRIP71pN OF OPERATIONS below E.L.DISEASE-POLICY LIMIT i$1 000 000 <br /> I <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may ba attached if more space Is required) <br /> A waiver of subrogation applies where required by written contact . <br /> CERTIFICATE HOLDER CANCELLATION <br /> Service Station Systems, Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> 3224 Regional Parkway ACCORDANCE WITH THE POLICY PROVISIONS, <br /> Santa Rosa, CA 95403 <br /> AUTHOR ZED REPRESENTATIVE <br /> t <br /> 0 1988-2015 ACORD CORPORATION.All rights reserved, <br /> ACORD 25(2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD <br /> #S49577197/M49574723 BLKZP <br />