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SERVSTA-CL SFRUSHOUR <br />C <br />CERTIFICATE I ILI INSURANCE DATE `MMODN" <br />6/3/2014 <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: H the certificate holder is an ADDITIONAL INSURED, the polky(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 endomement/sl. <br />PRODUCER A T <br />George Petersen Insurance Agency, Inc. PHASE <br />P.O. ox 3539 : (707) 525-4150 AIC No): (707) 525.4175 <br />Santa Rosa, CA 95402 _-_-__ <br />INSURED <br />i INSURER A • Insurance Company of the West <br />Service Station Systems, Inc. <br />3224 Regional Parkway <br />Santa Rosa, CA 95403 <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br />rurc IQ rn rCCMCV riser r.,� ..,.._-.•-- ••_-- _-- _-- <br />T <br />INDICATED. NOTWITHSTANDING VANY REL"'R'E yr uv.urwrvct us I. tstLUw HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />QUIREMENT, 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 />ILTR NISR1 <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />LIMITS <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE OCCUR <br />7EACH <br />OCCURRENCE $ <br />PREMISES Ea Ooourrence $ <br />MED EXP (Ah one person $ <br />PERSONAL 6 ADV INJURY $ <br />GEN L AGGREGATE LIMIT APPLIES PER <br />POLICYT LOC <br />GENERAL AGGREGATE $ <br />PRODUCTS-COMPIOPAGG $ <br />OTHER <br />$ <br />AUTOMOBILE LIABILITYCOMBINEDSINGLE$ <br />ANYAUTO <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />HIRED AUTOS NON -OWNED <br />AUTOS <br />LIMIT <br />Ee accident <br />BODILY INJURY (Perperson) $ <br />BODILY INJURY (Per soobent) $ <br />Pyr a�den DAMAGE $ <br />$ <br />UMBRELLA LIAR <br />EXCESS LIAR <br />OCCUR <br />CLAIMS -MADE <br />EACH OCCURRENCE $ <br />AGGREGATE $ <br />DED I I RETENTION <br />WORKERS COMPENSATION <br />AND EMPLOYERS, LUUMM <br />A OFFFFICPERR°ei�ERR EXCLUUDDED EcurrvE Y® <br />(Mandatory underE.L. <br />gr describe <br />CRIPTION OF OPERATIONS below <br />NIA <br />PL502130702 <br />06/04/2014 <br />06/04/2015 <br />S <br />X STATUTE ERH <br />E.L. EACH ACCIDENT $ 1,000,00 <br />DISEASE - EA EMPLOYE $ 1,000,00 <br />E.L.-'-TT DISEASE - POLICY LIMIT $ 1,000,00 <br />DESCRIP410N � tlPFGATrMde r r Mwr,rwc , vsu,n. <br />�� .. <br />- -- - ------ ----...._..-..-. ••••-�.. ,.,......,. ,o., Avmii n i Remarks xneauue, may be anschad H more space Is required) <br />License #485184 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />Contractor State License Board Workers Compensation Unit THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />PO Box 26000 ACCORDANCE WITH THE POLICY PROVISIONS. <br />Sacramento, CA 95826 <br />v eaov-`v w J%IoVKLP L.VKrUKA I [UK. All rights reserved. <br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD <br />