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ACOROR SERVSTA-01 ILICW <br /> �- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER1THIS <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 terns 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 License#0603247 CONTACT <br /> George Petersen Insurance Agency,Inc. NAME: <br /> P.O.Box 3539 PHONE (800)236-9046 <br /> Santa Rosa,CA 95402 A/C Ext: FAX No): (888)579-2743 <br /> E-MAILL <br /> ADDRESS: <br /> INSURERS AFFORDING COVERAGE NAIC N <br /> INSURED INSURER A:ICW Group <br /> INSURER B: <br /> Service Station Systems,Inc. INSURER C <br /> 680 Quinn Ave <br /> San Jose,CA 95112 INSURER D <br /> INSURER E: <br /> COVERAGESINSURER F <br /> CERTIFICATE NUMBER: REVISION NUMBER: <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT <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 /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,WITH RESPECT TO WHICH THIS <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR <br /> LTR TYPE OF INSURANCE POLICY NUMBER P LICY FF PO ICY EXP <br /> GENERAL LIABILITY MM /YYYY MMIDD/YYYY LIMITS <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br /> CLAIMS-MADE 7OCCUR <br /> PREMISES Ea occurrence $ <br /> MED EXP(Any one penton) $ <br /> PERSONAL 8 ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> POLICY PRO LOC PRODUCTS-COMP/OP AGG $ <br /> ECT <br /> AUTOMOBILE LIABILITY $ <br /> COMBINED SINGLE LIMIT <br /> ANY AUTO Es accident <br /> ALL OWNED SCHEDULED BODILY INJURY(Per person) $ <br /> AUTOS AUTOS <br /> NON OWNED BODILY INJURY(Per accident) $ <br /> HIRED AUTOS UTO <br /> AS PROPERTY DAMAGE <br /> Per accident $ <br /> UMBRELLA LIAB OCCUR $ <br /> EXCESS LIAR CLAIMS-MADE EACH OCCURRENCE $ <br /> AGGREGATE $ <br /> DED RETENTIONS <br /> WORKERS COMPENSATION $ <br /> AND EMPLOYERS'LIABILITY x TVRY TA IT OTH R <br /> A ANY PROPRIETOR/PARTNER/EXECUTIVEY/N <br /> OFFICERAIEMBER EXCLUDED? N/A PL502130700 6/4/2012 6/412013 <br /> ❑ E.L.EACH ACCIDENT $ 1,000,000 <br /> (Mandatory In NH) <br /> IT yes,describe under E.L.DISEASE-EA EMPLOYE $ 1,000,000 <br /> DESCRIPTION OF OPERATIONS below <br /> E.L.DISEASE-POLICY LIMIT $ 1,000,000 <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more space Is required) <br /> Proof of coverage <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Proof of Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> AUTHORIZED REPRESENTATIVE <br /> ©1988-2010 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD <br />