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HomeMy WebLinkAbout2022-23 __..--...N ® DATE(MM/DD/YYYY) A�Ro CERTIFICATE OF LIABILITY INSURANCE 10/02/2023 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 =1 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). .c PRODUCER CONTACT At Risk Services southwest, In NAME: 'O PHONE Dallas TX Office (A/C.No.Ext): (866) 283-7122 FAX No): (800) 363-0105 hi 5005 Lyndon B Johnson Freeway E-MAIL 0 Suite 1500 ADDRESS: _ Dallas Tx 75244 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: AIU Insurance Company 19399 SEI Speedway Holdings, LLC INSURER B: 3200 Hackberry Road Irving Tx 75063 USA INSURER C: INSURER D: 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 INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE DAMAGE 1 O REN rED CLAIMS-MADE I I OCCUR PREMISES(Ea occurrence) MED EXP(Any one person) PERSONAL&ADV INJURY 0 __.'_---_ -__ rn to GEN'LAGGREGATE LIMIT APPLIES PER: - -- GENERAL AGGREGATE U, r v POLICY I I JECT LOC L --''- PRODUCTS-COMP/OP AGG o I EC OTHER: Q{� n } AUTOMOBILE LIABILITY UCT 1 1 �- 23 COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) 0 OWNED SCHEDULED HEALTH DEPT. I z BODILY INJURY(Per accident) P. AUTOS ONLY AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE CO V —ONLY _AUTOS ONLY (Per accident) t 0) 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 0TH- EMPLOYERS'LIABILITY Y/N AOS ER ANY PROPRIETOR/PARTNER/EXECUTIVE (�7 E.L.EACH ACCIDENT S1,000,000 A OFFICER/MEMBEREXCLUDED? I N I N/A wC049154451 10/01/2023 10/01/2024 (Mandatory in NH) CA E.L.DISEASE-EA EMPLOYEE S1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below - E.L.DISEASE•POLICY LIMIT $1,000,000— Oil DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) a 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- a- CERTIFICATE HOLDER CANCELLATION L a -.. rn SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE m POLICY PROVISIONS. NZ; g ''• Town of Yarmouth AUTHORIZED REPRESENTATIVE 8 1146 Rt. 28 0 South Yarmouth MA 02664-4451 USA or 0 eSZA Y � f .ffac M ill ©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 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 ACORD certificate form for policy limits. POLICY POLICY INSR ADDL SUBR POLICY NUMBER EFFECTIVE EXPIRATION LIMITS LTR TYPE OF INSURANCE INSD WVD DATE DATE (MM/DD/YYYY) (MM/DD/YYYY) WORKERS COMPENSATION A N/A wc049154452 10/01/2023 10/01/2024 WI de 1- 12023 HEALTH DEPT. I 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#: -4CORG 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 aCT 1 1 Z0 HEATH DE:Pt a m co 0 N- g ACORD 101(2008/01) ®2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD