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11
<br />v
<br />,4 ®®DATE CERTIFICATE OF LIABILITYINSURANCE
<br />)
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL
<br />3/31/20111
<br />I
<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(ies) 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
<br />CONTACT Josie Gavieres
<br />NAME:
<br />Patriot Risk and Insurance ServicesHONE
<br />Ext: (949) 486-7900 ,AAX No) (949)486-7950
<br />License #OG55454
<br />ADDRESS:
<br />PRODUCER ID #:00000252
<br />8105 Irvine Center Dr. #400
<br />INSURER(S)AFFORDING COVERAGE NAIC#
<br />Irvine CA 92618
<br />INSURED
<br />INSURER A Anterican Safety Indemnity_ _ 25433
<br />INSURERB:Mercury Casualty_ -
<br />! PERSONAL & ADV INJURY
<br />�__
<br />Fueling and Service Technologies, Inc.,
<br />INSURER C:SeaBrj,_g Insurance Company 15563
<br />DBA: Fastech
<br />_ht - - - ------
<br />INSURER D
<br />7050 Village Drive, Suite D
<br />INSURER E:
<br />Buena Park CA 90621
<br />PRODUCTS - C
<br />RODOMP/OP AGG
<br />$
<br />INSURER F
<br />COVERAGES CERTIFICATE NUMBER:11-12 WC & 10-11 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 TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL
<br />THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />INSR I _- -_ ADDL WUBR'. ------ — POLICY_EFF —___.._.
<br />OLICY EXP
<br />LTR 1 TYPE OF INSURANCE INSR' WVD' POLICY NUMBER MAM/ DYY
<br />/YY MMIDDIYYYY
<br />I LIMITS
<br />GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$
<br />1,000,000
<br />'
<br />j X ',_COMMERCIAL GENERAL LIABILITY
<br />-
<br />DAMAGE TORENTED-
<br />;__PREMISES (Ea occurrence)
<br />S,
<br />_
<br />-
<br />_501,000
<br />-_
<br />A CLAIMS -MADE X 10/30/2010Ill/1/2011 OCCUR ENV0273281001
<br />ME D EXP (Any o ne person)
<br />$
<br />5,000
<br />$10, .... Deductible
<br />$10, 000 Deductible
<br />__......_._ ._.._ .._
<br />! PERSONAL & ADV INJURY
<br />�__
<br />$
<br />1,000,000
<br />__..
<br />X
<br />X Per Occcurrence
<br />GENERAL AGGREGATE
<br />$
<br />2,000,000
<br />'i GEN'L AGGREGATE LIMIT APPLIES
<br />S PER: li,
<br />PRODUCTS - C
<br />RODOMP/OP AGG
<br />$
<br />2,000,000
<br />JECT . -..,
<br />X POLICY PRO- LOC
<br />L._. . —.— .._..
<br />_.-
<br />$
<br />---. .. ----
<br />' AUTOMOBILE LIABILITY
<br />1 COMBINED SINGLE LIMIT
<br />$
<br />1,000,000
<br />X ANY AUTO
<br />^111/3/2010
<br />(Ea accident)
<br />- --- __
<br />'r BODILY INJURY (Per person)
<br />$
<br />---
<br />B �IALL OWNED AUTOS CCA0002559 111/3/2011
<br />BODILY INJURY (Per accident)
<br />$
<br />SCHEDULED AUTOS
<br />'
<br />:PROPERTY DAMAGE
<br />X ! HIRED AUTOS
<br />(Per accident)
<br />$
<br />_.,
<br />XNON-OWNED AUTOS'
<br />Uninsured motorist combined
<br />$
<br />100,000
<br />Medical payments
<br />$
<br />5,000
<br />X UMBRELLA LIAB X � OCCUR ''.
<br />EACH OCCURRENCE
<br />$
<br />4,000,000
<br />EXCESS LAB CLAIMS -MADE
<br />AGGREGATE
<br />$
<br />4,000,000
<br />DEDUCTIBLE
<br />_..
<br />A X RETENTION $ 10 000 ENU0273161001 10/30/20101,11/1/2011
<br />$
<br />C
<br />WORKERS COMPENSATION
<br />1, WC STATU '.OTH-'..
<br />X TORY LIMITS i__ ER____
<br />AND EMPLOYERS' LIABILITYYIN
<br />1-
<br />E.L. EACH ACCIDENT
<br />$
<br />1,000,000
<br />ANY PROPRIETOR/PARTNERIEXECUTIVE
<br />OFFtCER/MEMBER EXCLUDED? ❑ N I A
<br />(Mandatory in NH) 81112653
<br />/1/2011 4/1/2012
<br />E.DISEASE - EA EMPLOYEE,
<br />L1,000,
<br />$ _
<br />000
<br />j If yes, describe under
<br />E.L. DISEASE - POLICY LIMIT..
<br />$
<br />1,0001000
<br />DESCRIPTION OF OPERATIONS below'
<br />A
<br />(Pollution Liability YsNVD273281001 10/30/2010111/1/2011
<br />I
<br />Limit:
<br />I
<br />$
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
<br />Proof/Evidence of Insurance.
<br />30 days notice of cancellation, 10 days for non-payment of premium.
<br />CERTIFICATE HOLDER CANCELLATION
<br />ACORD 25 (2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved.
<br />INS025 (200909) The ACORD name and logo are registered marks of ACORD
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />Proof/Evidence of Insurance
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />Gary Hamilton/JOSIEG
<br />ACORD 25 (2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved.
<br />INS025 (200909) The ACORD name and logo are registered marks of ACORD
<br />
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