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SERVSTA-01 HFAHY <br /> CERTIFICATE OF t - F DATE(mmOD/YYYY) <br /> LIABILITY <br /> 1 6/24/2013 <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 O ACT <br /> George Petersen Insurance Agency,Inc. PHONE <br /> P.O.Box 3539 A E :(800)236-9046 4331 FwAiXX Ne:(707)525-4175 <br /> Santa Rosa,CA 95402 E-MAiL <br /> ADDRESS: <br /> INSURERS AFFORDING COVERAGE MAIC N <br /> INSURER A:Insurance Com any of the West <br /> INSURED <br /> ]- I'INEE <br /> : <br /> Service Station Systems,Inc. : <br /> 3224 Regional Parkway : <br /> Santa Rosa,CA 95403 <br /> : <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 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 /> II ADD <br /> LTR TYPE OF INSURANCE POLICY NUMBER PM�D/YYYFY MOL P LIMITS <br /> GENERAL LIABILITY WVD <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br /> PREMISES Ea occurrence $ <br /> CLAIMS-MADE OCCUR MED EXP(Any one person) $ <br /> PERSONAL BADV INJURY $ <br /> GENERALAGGREGATE $ <br /> GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ <br /> POLICY PRO LOC <br /> $ <br /> AUTOMOBILE LIABILITY COMBINED IN L I <br /> Ee accident) <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED <br /> AUTOS AUTOS BODILY INJURY(Per accident) $ <br /> NON-OHIRED AUTOS AUTOS <br /> NED PROPERTY DAMAGE <br /> AUTOS <br /> Per accident $ <br /> $ <br /> UMBRELLA OCCUR EACH OCCURRENCE <br /> EXCESS LIAR CLAIMS-MADE $ <br /> AGGREGATE $ <br /> DED RETENTION$ <br /> WORKERS COMPENSATION $ <br /> AND EMPLOYERS'LIABILITY Y/N X WC STATIUT- OTH. <br /> A ANY PROPRIETOR/PARTNER/EXECUTIVE PL502130701 6/4/2013 6/4/2014 $ 1,000,00 <br /> (ManOFFICER/MEMSER EXCLUDED? N/A E.L.EACH ACCIDENT <br /> firsstory In and E.L.DISEASE-EA EMPLOYE $ 1,000,00 <br /> M s,descibe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,K more space is <br /> "Proof of Coverage` required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Insured's Copy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> AUTHORIZED REPRESENTATIVE <br /> ©1988-2010 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD <br />