2015-611-E AMS - Blossman Gas, Inc. dba Alliance Autogas propane vehicle fuel

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DocuSign Envelope ID:02FOB961-A92E-4B1E-AOE9-E5777906432F 7111/12/2015 E(MM/DD/YYYY) ACCORD® CERTIFICATE OF LIABILITY INSURANCE 7/1/2016 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 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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONT PRODUCER Lockton Comparnes NAMEACT 444 W.47th Street,Suite 900 PHONE FAx Kansas City MO 64112-1906 E MAILo Ext: A/C,No (816)960-9000 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Liberty Mutual Insurance Company 23043 INSURED BLOSSMAN GAS,INC. INSURER B: 1318256 PO BOX 1110 INSURER C: OCEAN SPRINGS,MS 39564-4637 INSURER D INSURER E INSURER F COVERAGES BLOGA01 CERTIFICATE NUMBER: 13760478 REVISION NUMBER: XXXXXXX 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY • X COMMERCIAL GENERAL LIABILITY N N TB2641438890035 7/1/2015 7/1/2016 EACH OCCURRENCE $ 1,000,000 DAMAGE TO CLAIMS-MADE 1XI OCCUR PREMISES Ea occurrDence $ 100,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 PRO- JECT X POLICY LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ • AUTOMOBILE LIABILITY ITT ITT AS2641438890025 7/1/2015 7/1/2016 COMBINED SINGLE LIMIT $ Ea accident 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ XXXXXXX OWNED ALL AUTOS AUTO SCHEDULED BODILY INJURY(Per accident) $ XXXXXXX NON-OWNED PROPERTY DAMAGE $ XrXrXrXrXrXrXr HIRED AUTOS AUTOS Per accident $ XXXXXXX UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX EXCESS LIAB CLAIMS-MADE AGGREGATE $ XXXXXXX DED RETENTION$ $ XXXXXXX • AND EMPLOYERS'LIABILITY WORKERS COMPENSATION N WA764D438890015 7/1/2015 7/1/2016 X STATUTE EERH ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N N/A E.L.EACH ACCIDENT $ 1 000 000 OFFICER/MEMBER EXCLUDED? IN I (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION 13760478 ORANGE COUNTY ASSET MANAGEMENT SERVICES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PO BOX 8181 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 131 W.MARGARET LANE, SUITE 300 ACCORDANCE WITH THE POLICY PROVISIONS. HILLSBOROUGH NC 27278 AUTHORIZED REPRESENTATIV Z2 ©1988L 014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD