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S € RVSTA -CL <br /> WEES1 <br /> �- CERTIFICATE Off= LIABILITY 114SU ANCEF DAT9/2019 <br /> E (MIA/DDYYYY, <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER'T'IFICATE HOLDER, THIS <br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORT) ED BY THE POLICIES <br /> BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING IMSURER(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 /> PRODUCER Llcense # 0603247 CONTACT <br /> George Petersen insurance Agency , Inc . PHONE <br /> P .O . Box 3539 (AIC, No, Ext): (707) 5264950 FAX <br /> Santa Rosa, CA 95402 E-MAIL (A/C, No): (707) 5254975 <br /> ADDREss; info@gpins .com <br /> INSURERS AFFORDING COVERAGE NAIC 9 <br /> INSURED INSURER A ; Insurance COMpanV Of the {Test 27047 <br /> INSURER IB : <br /> Service Station Systems , Inc . INSURER C : <br /> 3224 Regional Parkway <br /> Santa Rosa , CA 95403 INSURER D : <br /> INSURER E ; <br /> INSURER F : — '. <br /> COVERAGES CERTIFICATE NUMEIM REVISION NUI BER : <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 ADDL SUERI= m8m POLICY NUMBER POLICY EFF POLICY EXP <br /> COMMERCIAL GENERAL LIABILITY LIMITS <br /> CLAIMS-MADE OCCUR EACHOCCURRENCE $ <br /> DAMAGE TO RENTED <br /> EREMISES e occls ce $ <br /> MED EXP (Any one Person $ <br /> GENTAGGREGATE LIMIT APPLIES PER: PERSONAL & ADV INJURY <br /> L <br /> CY JECT LpC GENERAL AGGREGATERLAU PRODUCTS - COMP/OP AGG <br /> IABILITY COMBINED SINGLE LIMIT $ <br /> $ <br /> SCHEDULED BODILY INJ RY Per ®reon <br /> LY AUTOSS LY AUTOS ONLY BROOPERNJ AMAGECcldenl $erecci nlA LIAB OCCUR $ <br /> IAB CLAIMS-MADE EACH OCCURRENCE $ <br /> RETENTION $ AGGREGATE <br /> A WORKERS COMPENSATION <br /> AND EMPLOYERS' LIABILITYPER OTH• <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE YIN PL 6029307 07 614/2019 6/4/2020 <br /> ppFFICstory n g�� EXCLUDE D9 N / A E.L. EACH ACCIDENT 1 ,DDO,ODO <br /> (Mandatory In NH) _ <br /> II yes, describe under E.L. DISEASE - EA EMPLOYE 190D0,000 <br /> DESCRIPTION OF OPERATIONS below <br /> E.L. DISEASE - POLICY LIMIT 190000000 <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101 , Additional Remarks Schedule, may be attached H more space is required) <br /> RE: Proof of Coverage <br /> I <br /> I <br /> i <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Proof of Coverage THE EXPIRATION DATE THEREOF, N0710E WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS , <br /> AUTHORIZED REPRESENTATIVE <br /> ACORD <br /> 25 (2016/03) © 19884015 ACORD CORPORATION . All rights reserved . <br /> The ACORD name and logo are registered marks of ACORD <br /> I <br /> E <br /> I <br />