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HomeMy WebLinkAboutApp-Certs-License-WC �_-1 ® DATE(MM/DO/YYYY) A Cr) CERTIFICATE OF LIABILITY INSURANCE 10/02/2029 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this ,.°—.f certificate does not confer rights to the certificate holder in lieu of such endorsement(s). .c PRODUCER CONTACT 0) Aon Risk Services Southwest, Inc. PHON: Dal 1 as TX Office (A/CC..NNo.Ext): (866) 283-7122 E FAX (800) 363-0105 tli 5005 Lyndon B Johnson Freeway E-MAIL Suite 1500 ADDRESS: 2 Dallas Tx 75244 USA INSURERS)AFFORDING COVERAGE NAIC# INSURED INSURER A: AIU Insurance Company 19399 SEI Speedway Holdings, LLC INSURERB: 3200 Hackberry Road Irving TX 75063 USA INSURER C: INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570102045590 REVISION NUMBER: • THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested INTRR TYPE OF INSURANCE INSDD WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MMlDD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE ( I OCCUR DAMAGE TO RENTEDPREMISES(Ea occurrence) MED EXP(Any one person) PERSONAL&ADV INJURY o rn GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE v POLICY I I PRO- LOCL--- PRODUCTS-COMP/OP AGG o OTHER: ('�'� o UV I 1 r t82� " AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) , ANY AUTO HEALTH DEPT. BODILY INJURY(Per person) Z OWNED SCHEDULED ', BODILY INJURY(Per accident) d AUTOS AUTOS ONLY NON OWNED PROPERTY DAMAGE V HIRED AUTOS ONLY _,AUTOS ONLY (Per accident) C) d UMBRELLA LIAB OCCUR EACH OCCURRENCE C.) EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION A WORKERS COMPENSATION AND WC049154450 10/01/2023 10/01/2024 x PER STATUTE OTH- EMPLOYERS'LIABILITY Y/N AOS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 A OFFICER/MEMBER EXCLUDED? N N/A WC049154451 10/01/2023 10/01/2024 (Mandatory in NH) — CA E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000— ME a7i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE: Speedway Store #2438 at 441 Main Street, West Yarmouth, MA, Speedway Store #2440 at 14 East Main Street, West Yarmouth, MA - and Speedway Store #2445 at 1353 Route 28, South Yarmouth, MA. ti- CO CERTIFICATE HOLDER CANCELLATION y m 0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE r` EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. .2.; 5 Town of Yarmouth AUTHORIZED REPRESENTATIVE o 1146 Rt. 28 South Yarmouth MA 02664-4451 USA `��x t Y�� M /�/ o iii ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 10039991 LOC#: A o ADDITIONAL REMARKS SCHEDULE Page _ of AGENCY NAMED INSURED Aon Risk Services Southwest, Inc. SEI Speedway Holdings, LLC POLICY NUMBER See Certificate Number: 570102045590 CARRIER NAIC CODE See Certificate Number: 570102045590 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S) AFFORDING COVERAGE NAIC# INSURER INSURER INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information,refer to the corresponding policy on the ACORI) certificate form for policy limits. POLICY POLICY INSR ADDL SUER POLICY NUMBER EFFECTIVE EXPIRATION LIMITS LTR TYPE OF INSURANCE INSD WAD DATE DATE (MM/DD/YYYY) ,.AIM/DD/YYYY) WORKERS COMPENSATION A N/A wc049154452 10/01/2023 10/01/2024 WI 1I2023 HEALTH DEPT. ACORD 101(2008,01) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 10039991 LOC#: A012 ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY NAMED INSURED Aon Risk Services Southwest, Inc. SEI Speedway Holdings, LLC POLICY NUMBER See Certificate Number: 570102045590 CARRIER NAIC CODE See certificate Number: 570102045590 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Named Insured Schedule 2Go Tesoro Company; 7-Eleven, Inc. ; Giant Four Corners, LLC; Giant Stop-N-Go of New Mexico LLC; Northern Tier Bakery LLC; Northern Tier Retail LLC PFJ Southeast LLC; SEI Speedway Holdings, LLC; Speedway LLC; Speedway of Massachusetts LLC; Speedway Prepaid card LLC; Speedway western Holdings LLC; * * Speedway.com LLC SWTO LLC; Tesoro Northstore Company; Tesoro Sierra Properties, LLC; Tesoro South Coast Company, LLC; Tesoro West Coast Company LLC; TRMC Retail LLC Western Refining Retail TRS I, LLC; Western Refining Retail TRS II, LLC western Refining Retail, LLC Western Refining Texas Retail Services, LLC WIP LLC bC1 1 1 ZO? HEALTH DEFT. a m C" rn 0 r- N O 8 O 8 ACORD 101(2008/01) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD