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SERVSTA-CL SFRUSHOUR <br /> CERTIFICATE OF LIABILITY INSURANCE FDAT6/3/2 DIYYYY) <br /> 13/3/2014 <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 be endorsed. If SUBROGATION IS WAIVED,subject to <br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br /> certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT <br /> NAME: <br /> Georga Petersen Insurance Agency,Inc. PHONE FAC <br /> P.O.BOX 3534 A!C N4, E>n:(707)525-4150 AIc Nol:(707)525-4175 <br /> Santa Rosa,CA 95402 E-MAIL <br /> ADDRESS: <br /> INSURER(S)AFFORDING COVERAGE NAIC N <br /> INSURER A:Insurance Company 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 <br /> 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 CONTRACTOR 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 POLICY NUMBER MMIDDfYYYY LICY EFF MMID� NYYY LIMITS <br /> LICY EXP <br /> LTR <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br /> CLAIMS-MADE F71 OCCUR PREMISES Ea occurrence $ <br /> MI=D EXP(Any one Person) $ <br /> PERSONAL 6 ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> POLICY 1 PRO- <br /> JECT 0 LOC PRODUCTS-COMP/OP AGG $ <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LI IT $ <br /> Ee accident <br /> ANYAUTO BODILY INJURY(Per person) $ <br /> ALL OWNED SCTOS HEDULED <br /> AUTOS AUBODILY INJURY(Per accident)_ <br /> NON-OWNED PROPERTY DAMAGE $ <br /> HIRED AUTOS AUTOS Per accident _ <br /> $ <br /> UMBRELLA LIAR OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAR CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ $ <br /> WORKERS COMPENSATION x PER OTH- <br /> AND EMPLOYERS'LIABILITY STATUTE ER <br /> A ANY PROPRIETOWPARTNERIEXECUTWE YIN NIA PL502130702 0610412014 0610412015 p.L,EACH ACCIDENT $ 1,000,00 <br /> OFFICERIMEMBER EXCLUDED? <br /> (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE $ 1,000,00 <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 <br /> DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be atteched N more space is required) <br /> RE:License 0485184 <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> CContractor State License Board Workers Compensation Unit THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> o ra 26000 ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Sacramento,CA 95826 <br /> AUTHORIZED REPRESENTATIVE <br /> OO 1988-2014 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD <br />