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<br />,,,,.., ARRO AUTOGAS A- 2014 -075 REVIEWED BY:
<br />EUNICE HEREDIA (PG I OF 13)
<br />,aC"Rbr CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MMIDDYYYYY)
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />9%25/2015
<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 G09892
<br />CONTACT Dave Belmont
<br />NAME
<br />Adler Belmont Dye Insurance Services, Inc.
<br />PHONE (605)540 -3900 1 FAX Iaosl540 --3901
<br />?�d�n rvg..��Sl.;- tAPG EVot.
<br />369 Marsh Street
<br />A R�ESS ,DBelmont @AdlerBelmontDye.com
<br />INSURERi§J AFFORDING COVERAGE
<br />_m.._._.
<br />NAIC A
<br />Suite 200
<br />IINSURERA.North River Insurance Company
<br />2',1105
<br />San Luis Obispo CA 93401
<br />INSURED
<br />INSURER B_United States Fire Insurance Cc
<br />21113
<br />San Luis Butane Distributors, Inc., DBA: Delta
<br />INSURER C: Insurance Company Of the West
<br />__ __. –
<br />2.7647
<br />1960 Ramada Dr.
<br />INSURER DRSUI Indemnity Company
<br />$ 50,000
<br />'..... INSURER E
<br />INSURER F
<br />Paso Robles CA 93446
<br />COVERAGES CERTIFICATE NUMBER :15- 16GL,AL,WC,UMB REVISION NUM'BEIR=
<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 />1NSR
<br />LTR
<br />TYPE OF INSURANCE
<br />AD ®L
<br />INSD
<br />SUBR
<br />WVD
<br />_.'.'..'.....'
<br />POLICY NUMBER
<br />PCbLICY EPF
<br />MMIDDIYYYY
<br />POLICY' EXP
<br />MM. DDIYYYY
<br />�... ...
<br />LIMITS
<br />X
<br />COMMERCIAL GENERAL. LIABiLIITY
<br />OCCURRENCE
<br />$ 1,000,000
<br />A
<br />CLAIMS -MADE � OCCUR
<br />rEACH
<br />AGE TO RENTED
<br />MiS � E k
<br />$ 50,000
<br />X
<br />5068826649
<br />9/29/2015
<br />9/29/2016
<br />... EXP (Any one person)
<br />$ 10 , 400
<br />SONAL 8 ADV INJURY
<br />$ �. 1 , 000, 000
<br />GEN
<br />L AGGREGATE LIMIT APPLIES PER':
<br />GENERAL. AGGREGATE
<br />$ 2,000,000
<br />X
<br />POLICY 1-1 PEQ II LOC
<br />PRODUCTS - COMPIOP AGG
<br />_
<br />..$...,.. 2,000,000
<br />Employee Benefits
<br />S 1,000,000
<br />OTHER:
<br />AUTOMOBILE. LIABILITY
<br />COM II
<br />BINED SINGLE LIMIT'
<br />Ea a.'oenk
<br />$ 1,000,000
<br />._
<br />BODILY INJURY (Per person)
<br />._.
<br />$
<br />ANY AUTO
<br />BODILY INJURY (Per accident)
<br />$
<br />ALL OWNED AUHEDLVLED
<br />AUTOS AUTOS
<br />._X__
<br />JX
<br />5068826649
<br />9/29/2015
<br />9/29/2016
<br />NON-OWNED
<br />PROPERTY- bAN1AGE
<br />$
<br />HIRED AUTOS AUTOS
<br />AUTOS
<br />I'er accident.
<br />$
<br />X UMBRELLA LDAB
<br />–
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 14 Ci44 440
<br />B
<br />EXCESS LAS
<br />CLAIMS-MADE
<br />AGGREGATE
<br />...$._._ 10 000 000
<br />DED ,...'RETENTION$
<br />$
<br />5238031671
<br />9/29/2015
<br />9/29/2016
<br />WORKERS COMPENSATION
<br />X PER OTH-
<br />AND EMPLOYERS' LIABILITY YIN
<br />'... STATUTE, m.m I ER
<br />E . L. EACH ACCIDENT
<br />$ 1 _L 044
<br />ANY
<br />?ECUTIVE LT-"T
<br />NIA'
<br />C
<br />OPFICERIMEMBERI EXCLUDED
<br />E:.L...DYSEAS. E .E - EA EMPLOYE
<br />..
<br />$ 1,000,000
<br />(Mandatory in NH)
<br />WSA500687304
<br />10/1/2.015
<br />10/1/2016
<br />If yea, describe under.
<br />-_ ---- --
<br />_..- _....�
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1.000 000'
<br />''.. D
<br />Excess Liability
<br />NEA,238774
<br />09/29/2015
<br />09/29/2016
<br />Aggregate Liability Limit. $5,000,440
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
<br />See forms attached as triggered by written contract:
<br />GL: AI- CG2026 0704, PNC- FM101.0.1206 01,1,1, 30DNOC- Co .fallow from carrier.
<br />RE: New propane Fueling Station -Fleet Services,.
<br />City of Santa Ana
<br />24 Civic Center plaza
<br />Santa Arta, CA 92702
<br />ACORD 25 (2014101)
<br />INS025120140II I
<br />L'i -11l11111111 IlIN W=71[iJ@
<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 />AUTHORIZED REPRESENTATIVE
<br />Dave 13e11mc:)nt /LAURA
<br />@ 1988 -2014 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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