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SERVSTA-CL CMEESI <br /> A� CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) <br /> 5/29/2019 <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 INSURE: R(S), AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy( ies) 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 )a <br /> License # 0603247 41, T <br /> PRODUCER --- - <br /> George Petersen Insurance Agency, Inc. PH10 N E,,,): (707) 5254150 FAX No):(707) 525-4175 <br /> P .O . Box 3639 E-MAIL info lns . com <br /> Santa Rosa, CA 95402 }- ADD_ : gP <br /> INSURER(SI AFFORDING COVERAGE _ NAIC # <br /> INSURER A : Insurance Company of the West _ 27847 <br /> INSURED INSURER B : <br /> Service Station Systems , Inc. INSURER C : _,�__ <br /> 3224 Regional Parkway INSURER 0 : <br /> Santa Rosa , CA 95403 INSURER E :INSURER F : <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 /> 'NSR TYPE OF INSURANCE EADDL SUBR� � POLICY NUMBER MPO�pCY EFF PMLICY EXP LIMITS <br /> LTR COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $ <br /> — DAMAGE TO RENTED <br /> CLAIMS-MADE OCCUR <br /> PREM) ES!E�oyoVgknce $ <br /> MED EXP tAnv one personi $ <br /> PERSONAL & ADV INJURY <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> POLICY ❑ jPCC F] LOC PRODUCTS.mCOMP/OP AGG $ <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY ( COMBINED SINGLE LIMIT <br /> !� ANY AUTO =BODILY Per p2.rsg_91. $ ._ <br /> I AUTOS ONLY SCHEDULED BRORDILY INJURY (Per accident) 5 <br /> ���pAUTOS <br /> p pyy�� Lva9dTen1 AMAGE $ <br /> I AUTOS ONLY AR ON 9 1 i <br /> $ <br /> I UMBRELLA LIAB OCCUR EACH OCCURRENCE S _ <br /> EXCESS LIA 1H CLAIMS-MADE AGGREGATE $ <br /> DEDW RETENTION $ $ <br /> A WORKERS COMPENSATION <br /> AND EMPLOYERS' LIABILITY I I <br /> YIN WPL $021307 07 6/412019 <br /> ANY PROPRIETOR/PARTNERlEXECUTIVE 61412020 E.L. EACH ACCIDENT I $ 1 ,000, 000 <br /> OFFICERr��M MgER) EXCLUDED? NIA 1 ,000,000 <br /> It andatcrry�n Nfi) E.L. DISEASE - EA EMPLOYEE $ <br /> If yes, describe under E.L. DISEASE - POLICY LIMIT $ 110002000 <br /> DESCRIPTION OF OPERATIONS balax <br />{ <br />€ DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (ACORD 101 , Additional Remarks Schedule, may be attached if more apace is required) <br />! RE: Proof of Coverage <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> Proof of Coverage ACCORDANCE WITH THE POLICY PROVISIONS. <br /> AUTHOR <br /> IZED REPRESENTATIVE <br /> ACORD 25 (2016103) © 1986 -2015 ACORD CORPORATION , All rights reserved . <br /> The ACORD name and logo are registered marks of ACORD <br /> I <br />