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SERVSTA-01 HFAHY 'AC- "`r" CERTIFICATE OF LIABILITY INSURANCE DATE 6/24//201(M201YYY) 3 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER George Petersen Insurance Agency, Inc. P.O. Box 3539 CONTACT NAME: PHONE g00 236-9046 4331 Fox (707) 525-4175 A/C No Ext : ( ) AIC No Santa Rosa, CA 95402 E-MAIL - ---- ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC k LIMITS INSURER A: Insurance Company Of the West GENERAL LIABILITY INSURER 8: INSURED INSURER C : Service Station Systems, Inc. INSURER D: 3224 Regional Parkway Santa Rosa, CA 95403 INSURER E: INSURER F: COMMERCIAL GENERAL LIABILITY COVERAGES CERTIFICATE NUMBER: RFVIRInN NIIMl la• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE AUTHORIZED REPRESENTATIVE POLICY NUMBER POLICY EFF MM/DDNYYY POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ KILN ILL) PREMISES Ea occurrence $ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 71OCCUR MED EXP (Any one person) $ _ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ UMBRELLA LAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ EXCESS LIAR AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION X WC STATU- OTH- TORY LIMITS R AND EMPLOYERS' LIABILITY Y / N E.L. EACH ACCIDENT $ 1,000,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE PL502130701 6/4/2013 6/412014 OFFICER/MEMBER EXCLUDED? a N I A E.L. DISEASE - EA EMPLOYEE $ 1,000,00 (Mandatory In NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) *Proof of Coverage* CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Insured's Copy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD