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SERVSTA-CL DWATTS <br /> '4�o�zo CERTIFICATE OF LIABILITY INSURANCE P A TE(M <br /> 5/23//201201YYY) <br /> 6 <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(les)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 /> George Petersen Insurance Agency,Inc. PHONE 525-4150 FAx <br /> P.O.Box 3539 A/C No Ext):(707) A/C No):(707)525-4175 <br /> E-MAIL <br /> Santa Rosa,CA 95402 ADDRESS:Info@gpins.Com <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURER A:Insurance Company of the West, 7847— <br /> INSURED INSURER B: �- - <br /> Service Station Systems,Inc. INSURER C: <br /> 3224 Regional Parkway INSURER D: 4 M16 <br /> Santa Rosa,CA 95403 INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBIER: <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 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 7ypE OF INSURANCE A D S BR POLICY EFF POLICY EXP LIMITS <br /> LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DDM(YY <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br /> DAMAGE TO TE <br /> CLAIMS-MADE F�OCCUR PREMISES Ea occurrence $ <br /> MED EXP(Any one person) $ <br /> PERSONAL&ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> POLICY� PRO--ECT ❑ LOC PRODUCTS-COMP/OP AGG $ <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> Ea accident <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS AUTOS <br /> NON-OWNED PROPERTY DAMAGE $ <br /> HIREDAUTOS AUTOS Per accident <br /> UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED I I RETENTION$ $ <br /> WORKERS COMPENSATION X PER TH- <br /> AND EMPLOYERS'LIABILITY STATUTE ER <br /> YIN <br /> A ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A WPL 5021307 04 06/04/2016 06/04/2017 E.L.EACH ACCIDENT $ 1,000,000 <br /> OFFICER/MEMBER EXCLUDED? <br /> (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 <br /> If yes,describe under 1 000,000 <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ , <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) <br /> RE:License#485184 <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Compensation Unit THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> Contractor State License Board Workers Com <br /> p ACCORDANCE WITH THE POLICY PROVISIONS. <br /> PO Box 26000 <br /> Sacramento,CA 95826 <br /> AUTHORIZED REPRESENTATIVE <br /> 1 WX. <br /> \��` ©1988-2014 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD <br />