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ACCOR " CERTIFICATE OF LIABILITY INSURANCE1 <br />DATE (MM/DD YYYY) <br />9/26/2014 <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: 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 0G09892 <br />Adler Belmont Dye Insurance Services, Inc. <br />369 Marsh Street <br />Suite 200 <br />San Luis Obispo CA 93401 <br />CONTACT Britni Parsons <br />NAME: <br />FAX <br />A/C NNo, Ext: (805)540-3900 A/C No: (805)540-3901 <br />E-MAIL bparsons@adlerbelmontdye.com <br />ADDRESS: e.com <br />INSURER(S) AFFORDING COVERAGE NAIC# <br />INSURERA:North River Insurance Company 1105 <br />INSURED <br />San Luis Butane Distributors, Inc. <br />(See attached for Additional Named Insureds) <br />1960 Ramada Drive <br />Paso Robles CA 93446 <br />INSURERB:United States Fire Insurance Co 21113 <br />INSURER C: Insurance Company of the West7847 <br />INSURERD:Certain Underwriters at Lloyd's <br />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER:14-15 Master All Lines 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 />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />INSR <br />SUBR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MM/DD/YYY <br />POLICY EXP <br />MM/DD/YYY <br />LIMITS <br />GENERAL LIABILITY <br />EACH OCCURRENCE $ 1,000,000 <br />X COMMERCIAL GENERAL LIABILITY <br />DAMAGE RENTED <br />PREM SESOEa occurrrence $ 100,000 <br />A <br />CLAIMS -MADE Fx_1 OCCUR <br />X <br />5068779732 <br />9/29/2014 <br />9/29/2015 <br />MED EXP (Any one person) $ 10,000 <br />PERSONAL & ADV INJURY $ 1,000,000 <br />GENERAL AGGREGATE $ 2,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />PRODUCTS - COMP/OP AGG $ 2,000,000 <br />X POLICY PRO LOCI <br />$ <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea accident $ 1,000,000 <br />BODILY INJURY (Per person) $ <br />A <br />X <br />ANY AUTO <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />068779732 <br />9/29/2014 <br />9/29/2015 <br />BODILY INJURY (Per accident) $ <br />PROPERTY DAMAGE $ <br />Per accident <br />XX <br />NON -OWNED <br />HIRED AUTOS AUTOS <br />Medical payments $ 5,000 <br />UMBRELLA LAB <br />OCCUR <br />EACH OCCURRENCE $ 10,000,000 <br />AGGREGATE $ 10,000,000 <br />B <br />X <br />EXCESS LAB <br />CLAIMS -MADE <br />5238005121 <br />DED RETENTION$ <br />$ <br />9/29/2014 <br />9/29/2015 <br />C <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY Y / N <br />ANY PROPRIETOR/PARTNER/EXECUTIVE <br />OFFICER/MEMBER EXCLUDED? <br />(Mandatory in NH) <br />N/A <br />SA500687303 <br />10/1/2014 <br />10/1/2015 <br />X WC STATU- OTH- <br />TORY LIMITS ER <br />E.L. EACH ACCIDENT $ 1,000,000 <br />E.L. DISEASE - EA EMPLOYE $ 1,000,000 <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE - POLICY LIMIT $ 1,000,000 <br />D <br />Excess Liability <br />14RENMA14000156068700 <br />9/29/2014 <br />9/29/2015 <br />Aggregate Liability $5,000,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) <br />See forms attached as triggered by written contract: <br />GL: AI- CG2026 0704, PNC- FM101.0.1206 0111, 30DNOC- To follow from carrier. <br />RE: New propane Fueling Station -Fleet Services. <br />Desr U1191 -g IDI 'v M36 - ?age Of 13 <br />CERTIFICATE HOLDER CANCELLATION <br />ACORD 25 (2010/05) <br />INS025 (201005).01 <br />© 1988-2010 ACORD CORPORATION. All rights reserved. <br />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 />ACCORDANCE WITH THE POLICY PROVISIONS. <br />City of Santa Ana <br />20 Civic Center Plaza <br />AUTHORIZED REPRESENTATIVE <br />Santa Ana, CA 92702 <br />Britni Parsons/BRITNI <br />ACORD 25 (2010/05) <br />INS025 (201005).01 <br />© 1988-2010 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />