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A m a <br />SERVSTA-01 ILICHALI <br />"�- CERTIFICATE OF LIABILITY I S NCEDATE(MM/DDNYYY) <br />6/6/2012 <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 License # 0603247 <br />George Petersen Insurance Agency, Inc. <br />P.O. Box 3539 <br />Santa Rosa, CA 95402 <br />C NTACT <br />PHONE <br />a No Ext): (800) 236-9046 FAX No): (888) 579-2743 <br />E-MAIL <br />ADDRESS: <br />INSURER(S) AFFORDING COVERAGE NAIC # <br />INSURED <br />INSURER A: lCW GrOup <br />INSURER B: <br />Service Station Systems, Inc. <br />680 Quinn Ave <br />San Jose, CA 95112 <br />INSURER C <br />INSURER D: <br />INSURER E: <br />INSURER c: <br />COVFRBrFtq I+MOrerrrwr� ..U.. <br />— — — RCVISIUN NUMBER: <br />S 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 />TIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />LUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR ADDL <br />LTR <br />TYPE OF INSURANCE <br />GENERAL LIABILITY <br />N <br />POLICY NUMBER <br />MMD <br />MD <br />LIMITS <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE $ <br />A <br />CW MS MADE F—IOCCUR <br />PREMISES Ea occurrence $ <br />MED EXP (Any one person) $ <br />PERSONAL & ADV INJURY $ <br />GENERAL AGGREGATE $ <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />POLICY PRO L� <br />PRODUCTS -COMP/OP AGG $ <br />$ <br />AUTOMOBILE <br />LIABILITY <br />ANY AUTO <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />NON -OWNED <br />HIRED AUTOS AUTOS <br />AUTOS <br />COMBINED SINGLE LIMIT <br />Ea accident <br />BODILY INJURY (Per person) $ <br />BODILY INJURY (Per accident) $ <br />PROPERTY DAMAGE <br />Per accident $ <br />UMBRELLA LIAB <br />EXCESS LIAR <br />OCCUR <br />CLAIMS -MADE <br />FACH OCCURRENCE $ <br />AGGREGATE $ <br />DED RETENTION$ <br />A <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />N <br />ANY PROPRIETOR/PARTNER/EXECUTIVE YIN <br />OFFICERIMEMBER EXCLUDED? El <br />(Mandatory In NH) <br />H yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />N / A <br />PL502130700 <br />6/4/2012 <br />6/4/2013 <br />$ <br />X RY AIT ER <br />E.L. EACH ACCIDENT $ 1,000,00 <br />E.L. DISEASE - EA EMPLOYE $ 11000,000 <br />E.L. DISEASE - POLICY LIMIT $ 1,000,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) <br />Proof of coverage <br />reorrrrnwr� Un. — <br />Proof of Coverage <br />CANCELLATION <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />rHORIZED REPRESENTATIVE <br />( J. <br />©1988-2010 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD <br />