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SERVSTA -CL CMEESI <br /> DATE (MM/DDIYYYY) <br /> CERTIFICATE OF LIABILITY INSURANCE 5/29/2019 <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 have ADDITIONAL INSURED provisions or be endorsed . <br /> If SUBROGATION IS WAIVED , subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br /> this certificate does not confer rights to the certificate holder In lieu of such endorsement(s ). <br /> License # 0603247 CONTACT <br /> PRODUCER AME: <br /> PHONEFAX 525-4175 <br /> George Petersen Insurance Agency , Inc . (AIc, No, Ext): (707) 525 -4150 (AIC, No): (707) <br /> P .O . Box 3539 IADDRESS : info@gpins . com <br /> Santa Rosa , CA 95402 <br /> INSURERS AFFORDING COVERAGE NAIC # <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 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TOWHICH 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 ADSD SUBDR POLICY EFF POLICY EXP LIMITS '.. <br /> T TYPE OF INSURANCE POLICY NUMBER DD <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br /> DAMAGE TO RENTED <br /> CLAIMS-MADE OCCUR PREMI ES Ea occurrence $ ,._,_._ <br /> MED EXP (Any oneperson) $ <br /> PERSONAL & ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> POLICY ❑ JE� LOC PRODUCTS - COMP/OP AGG <br /> OTHER: COMBINED BDISINGLE LIMIT $ <br /> AUTOMOBILE LIABILITY (Ea _ <br /> ANY AUTO BODILY INJURY Perperson) $___ <br /> OWNED SCHEDULED BODILY INJURY Per accident $ ,_- <br /> AUTOS ONLY AUT SSWN p PROPERTY AMAGE <br /> AUTO ONLY AUTOS ONLY Per acc dent $ <br /> UMBRELLA LIAR OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAR CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION $ $ <br /> X STAT E EERH <br /> A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN WPL 5021307 07 6/4/2019 6/4/2020 110001000 <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ <br /> OFFICER/MEMBER EXCLUDE D9 ❑ NIA 1 , 000 ,000 <br /> (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ <br /> If es, describe under E.L. DISEASE - POLICY LIMIT $ 1 '000' 000 <br /> DESCRIPTION OF OPERATIONS below <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101 , Additional Remarks Schedule, may be attached if more space is required) <br /> RE : Proof of Coverage <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> Proof of Coverage ACCORDANCE WITH THE POLICY PROVISIONS . <br /> AUTHORIZED REPRESENTATIVE '.. <br /> © 1988 -2015 ACORD CORPORATION . All rights reserved . <br /> ACORD 25 ( 2016103) <br /> The ACORD name and logo are registered marks of ACORD <br />