CTR063573 Certificate of Insurance Approved.pdf

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

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.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

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.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2016 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

B

1,000,000

XSL G48948510

ATL-005508658-10

1,000,000

5,000,000

SIR: 1,000,000

X

20079

5,000,000

ATLANTA, GA 30326

N

X

MCS-90

SIR $1,000,000

09/01/2024

09/01/2025

09/01/2025

XSA H1137265A

A

16,000,000

4,000,000

National Fire & Marine Insurance Co

1,000,000

X

X

08/15/2024

09/01/2024

ARIZONA DEPARTMENT OF TRANSPORATION ADOT and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees are Included as Additional Insured (except Workers Compensation) where required by written contract. This insurance is Primary and Non-Contributory over any existing insurance and limited to liability arising out of the operations of the named insured

X

Arizona Department of Public Safety

1324 N. 22nd Ave MD 128A

The State of Arizona

Phoenix, AZ 85009

25,000 subject to policy terms and conditions. Waiver of subrogation is applicable where required by written contract and subject to policy terms and conditions.

X

A

CN102968394--GAWU-24-25

$0

09/01/2025

9,000,000

42UMO30858306

'SIR: $1,000,000'

1,000,000

22667

100,000

X

1,000,000

WCU C72621360 (AOS)

TWO ALLIANCE CENTER

MARSH USA, LLC.

X

3560 LENOX ROAD, SUITE 2400

P.O. Box 10146

09/01/2024

Arizona Department of Transportation

X 09/01/2024

X

X

A X

09/01/2025

ACE American Insurance Company

X

Tartan Oil LLC

Knoxville, TN 37939

G0171 Accepted

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

Policy #: GVE100232306�

WC: Per Statutory - Excess NV�

Effective Date: 09/01/2024 Expiration Date: 09/01/2025�

Effective Date: 09/01/2024 Expiration Date: 09/01/2025�

SIR: $1,000,000�

WC: Per Statutory - Excess - (AZ, CA, CO, CT, DE, IA, ID, KS, MA, MD, ME, MN, MO, MS, MT, NC, NE, NH, NJ, NM, NY, OK, SD, TN, TX, UT, WV)�

Effective Date: 09/01/2024 Expiration Date: 09/01/2025�

Policy Number: WCU C7262144A (ACE American Insurance Company)�

MA, MD, ME, MI, MN, MO, MS, MT, NC, NE, NH, NJ, NM, NV, NY, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WI, & WV.�

PRIMARY COVERAGE:�

Policy #: P00100140728801�

WORKERS COMPENSATION:�

Policy Number: SCF C72621323 (ACE Fire Underwriters Insurance Company)� WC: Per Statutory - WI�

Atlanta

Effective Date: 09/01/2024 Expiration Date: 09/01/2025� Policy Number: WLR C72621281 (ACE American Insurance Company)�

Limit: $1,000,000 EL Limit �

Workers Compensation Continued:�

WC: Per Statutory - Fernley, NV�

Certificate of Liability Insurance

Limit: $1,000,000 EL Limit �

CN102968394

Ins Carrier: Axis Surplus Insurance Company�

Effective Date: 09/01/2024 Expiration Date: 09/01/2025�

Excess Auto Liability�

Ins Carrier: Gemini Insurance Company�

Policy Number: WCU C72621402 (ACE American Insurance Company)�

Limit: $1,000,000 EL Limit �

Effective Date: 09/01/2024 Expiration Date: 09/01/2025�

Limit: $1,000,000 EL Limit �

Policy Number: WLR C72621244 (ACE American Insurance Company)�

Effective Date: 09/01/2024 Expiration Date: 09/01/2025�

Workers Compensation "AOS" Policy includes coverage for employees from the following States WHILE WORKING IN ANY STATE:AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, SIR: $500,000 �

Liability, this applies to both ongoing and completed operations.�

MARSH USA, LLC.�

Limits: $2,000,000 excess $13,000,000 each occurrence/aggregate�

The General Liability and Automobile Liability policies are primary and not excess of or contributing with other insurance or self-insurance, where required by written lease or written contract. For General

P.O. Box 10146�

WC: Per Statutory - TN - Excess�

Limits: $3,000,000 excess $10,000,000 each occurrence/aggregate�

Limit: $1,000,000 EL Limit �

Tartan Oil LLC�

Knoxville, TN 37939

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

The Liability Limit that applies is the amount indicated on the face of this Certificate of Liability Insurance, or the minimum Liability limit that is required by the written contract, whichever is less. If there is no

If ACE American Insurance Company cancels this Policy prior to its expiration date by notice to the first Named Insured for any reason other than nonpayment of premium, ACE American Insurance Company party whom ACE American Insurance Company is required to notify by statue and in accordance with the cancellation provision of the General Liability, Auto Liability and Workers' Compensation Policies.�

THIS CERTIFICATE OF LIABILITY INSURANCE, AND EACH OTHER PERSON OR ORGANIZATION REQUIRED TO BE INCLUDED AS AN ADDITIONAL INSURED PURSUANT TO A WRITTEN For General Liability, if required by written contract, the following are included as additional insureds, as required pursuant to a written contract with a named insured: THE CERTIFICATE HOLDER LISTED ON

Atlanta

The Automobile Liability policy, if required by written contract, includes coverage for Additional Insureds as required by such written contract.�

ADDITIONAL INSURED - AUTOMOBILE LIABILITY:�

ADDITIONAL INSURED - GENERAL LIABILITY:�

The General Liability, Automobile Liability, Workers’ Compensation and Employers Liability policies include a Waiver of Subrogation in favor of the certholder and any other person or organization, BUT ONLY

WAIVER OF SUBROGATION:�

to the extent required by written contract.�

Certificate of Liability Insurance

ACE American Insurance Company will only be responsible for sending such notice to Named Insured's representative, and Named Insured's representative will in turn send the notice to the persons or

CN102968394

CONTRACT WITH THE NAMED INSURED.�

LIMIT OF LIABILITY: �

contract then the Liability Limit is limited to $1,000,000.� will endeavor, as set out in the endorsement, to send written notice of cancellation, to the persons or organizations listed in the Schedule that the Named Insured creates or maintains (the "Schedule") by

NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS:�

organizations listed in the Schedule at least 30 days prior to the cancellation date applicable to the General Liability, Auto Liability and Workers' Compensation Policies. Named Insured will cooperate with ACE

MARSH USA, LLC.�

P.O. Box 10146� allowing Named Insured's representative to send such notice to such persons or organizations. This notice will in addition to ACE American Insurance Company notice to the Named Insured, and any other

American Insurance Company in providing the Schedule, or in causing Named Insured's representative to provide the Schedule.

Tartan Oil LLC�

Knoxville, TN 37939

SCHEDULE OF NAMED INSURED ENDORSEMENT

(without joint ventures exclusion)

Named Insured Endorsement Number

Pilot Travel Centers LLC 12

Policy Symbol I Policy Number I Policy Period Effective Date of Endorsement

XSL G48948510 09/01/2024 to 09/01/2025 Issued By (Name of Insurance Company)

ACE American Insurance Company

Insert the policy number. The remainder of the mformat1on 1s to be completed only when this endorsement 1s issued subsequent to the preparation of the policy.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

This endorsement modifies insurance provided under the following:

Schedule:

COMMERCIAL GENERAL LIABILITY COVERAGE FORM

EXCESS COMMERCIAL GENERAL LIABILITY POLICY

Pilot Travel Centers LLC Pilot Receivables LLC Kearney I LLC PTC Kearney II LLC PTC Kearney 111 LLC PTC Kearney IV LLC PTC Delaware LLC PTCM Texas, L.P.

Pilot of Texas LLC Martin-Pilot Joint Venture FJI Plaza Company II LLC J Fleet Leasing LLC Fleet Sales LLC Beverage Management Associates, Inc.

Texas South I LLC Texas South II LLC Texas South Ill LLC Pilot Manning LLC PFJ Southeast LLC Parts and Service Solutions LLC BunkerHill Oil Marketing LLC BunkerHill Trading LLC Tartan Oil LLC Saratoga Rack Marketing LLC GreenAmerica Biofuels LLC Pilot Arizona Pride LLC Pilot Arizona South LLC Pilot Pacific Northwest LLC Pilot West Texas LLC Bunkerhill Holdings Company LLC Tri-Star DEF LLC Saratoga RP East LLC Fuelbook LLC HalfSpin Finance Holdings LLC Hyperion Employee Co LLC Hyperion EmployeeCo Holdings LLC Hyperion Water Holdings LLC Hyperion Water Technologies LLC

LD-20040 (02/06) Page 1 of 2

G0171 Highlight

PFJE AssetCo Holdings LLC PFJE Holdings LLC Pilot California Venture LLC Pilot West LLC Pilot Xpress Arizona LLC Pilot Xpress LLC Restover Truck Stop, LLC Starlight Relativity Holdings LLC Trajectory Acquisition Company LLC Pro Petroleum LLC Fuel Processing Operators, LLC Pro Terminal Operators, LLC Caljet of America, LLC Quikjet, LLC GreenAmerica BioFuel Ord LLC Southern Counties Oil Co., a California Limited Partnership and any organization over which you or any of your subsidiaries currently maintains majority ownership or a minority interest provided there is no other similar insurance available to that organization; and any other organization you newly acquire or form and over which you maintain majority ownership or a minority interest; provided:

a) there is no other similar insurance available to that organization; and

b) you notify us of such acquisition not later than 60 days after the policy period.

As respects newly acquired or formed organizations:

1. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization; and

2. Coverage B does not apply to "personal injury'' or "advertising injury" (or "personal and advertising injury'' if so defined in your policy) arising out of an offense committed before you acquired or formed the organization.

Authorized Agent

LD-20040 (02/06) Page 2 of2

ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION

Named Insured Endorsement Number

Pilot Travel Centers LLC 3

Policy Symbol I Policy Number I Policy Period Effective Date of Endorsement

XSL G48948510 09/01/2024 to 09/01/2025 Issued By (Name of Insurance Company)

ACE American Insurance Company

Insert the policy number. The remainder of the mformat1on 1s to be completed only when this endorsement 1s issued subsequent to the preparation of the policy .

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

This endorsement modifies insurance provided under the following:

EXCESS COMMERCIAL GENERAL LIABILITY POLICY

SCHEDULE

Name of Person or Organization: Any person or organization whom you have agreed to include as an additional insured under a written contract, provided such contract was executed prior to the date of loss.

A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf:

1. In the performance of your ongoing operations; or

2. In connection with your premises owned by or rented to you.

However:

1. The insurance afforded to such additional insured only applies to the extent permitted by law; and

2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following is added to Section Ill - Limits Of Insurance And Retained Limit:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable Limits of Insurance shown in the Declarations;

whichever is less.

This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.

Authorized Representative

XS-6W25b (04/13) Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1

ADDITIONAL INSURED - OWNERS, LESSEES OR

CONTRACTORS - COMPLETED OPERATIONS

Named Insured Endorsement Number

Pilot Travel Centers LLC 4

Effective Date of Endorsement Policy Symbol I Policy Number

XSL G48948510

I Policy Period

09/01/2024 to 09/01/2025 Issued By (Name of Insurance Company)

ACE American Insurance Company

Insert the policy number. The remainder of the mformat1on 1s to be completed only when this endorsement 1s issued subsequent to the preparation of the policy.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

This Endorsement modifies insurance provided under the following:

EXCESS COMMERCIAL GENERAL LIABILITY POLICY

SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations

Any person or organization whom you have agreed to All locations where you perform work for such additional include as an additional insured under a written insured pursuant to any such written contract.

contract, provided such contract was executed prior to the date of loss.

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organiza tion(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorse ment performed for that additional insured and included in the "products-completed operations hazard".

However:

1. The insurance afforded to such additional insured only applies to the extent permitted by law; and

2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following is added to Section Ill - Limits Of Insurance And Retained Limit:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable Limits of Insurance shown in the Declarations;

whichever is less.

This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.

XS-21164a (04/13) Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1

CHUBB® 1

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US

Named Insured Endorsement Number

Pilot Travel Centers LLC 2

Policy Symbol I Policy Number I Policy Period Effective Date of Endorsement

XSL G48948510 09/01/2024 to 09/01/2025 Issued By (Name oflnsurance Company)

ACE American Insurance Company

Insert the pohcy number. The remamder of the mformation 1s to be completed only when this endorsement 1s issued subsequent to the preparation of the pohcy.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

This endorsement modifies insurance provided under the following:

EXCESS COMMERCIAL GENERAL LIABILITY POLICY

SCHEDULE

Name of Person or Organization: Any person or organization against whom you have agreed to waive your right of recovery in a written contract, provided such contract was executed prior to the date of loss.

The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV - Conditions:

We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this policy. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above.

All Other Terms And Conditions Remain Unchanged.

XS-6W34a (02/20) Page 1 of1

NON-CONTRIBUTORY ENDORSEMENT FOR ADDITIONAL INSUREDS

Pilot Travel Centers LLC 7

Policy Symbol I Policy Number I Policy Period Effective Date of Endorsement

XSL G48948510 09/01/2024 to 09/01/2025 Issued By (Name of Insurance Company)

ACE American Insurance Company

Insert the policy number. The remainder of the mformat1on 1s to be completed only when this endorsement 1s issued subsequent to the preparation of the policy .

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

This endorsement modifies insurance provided under the following:

EXCESS COMMERCIAL GENERAL LIABILITY POLICY

Schedule

Organization Any additional insured with whom you have agreed to provide such non-contributory insurance, pursuant to and as required under a written contract executed prior to the date of loss.

Additional Insured Endorsement

(If no information is filled in, the schedule shall read: ''All persons or entities added as additional insureds through an endorsement with the term "Additional Insured" in the title)

For organizations that are listed in the Schedule above that are also an Additional Insured under an endorsement attached to this policy, the following is added to Section IV.4:

If other insurance is available to an insured we cover under any of the endorsements listed or described above (the "Additional Insured") for a loss we cover under this policy, this insurance will apply to such loss and is primary (subject to satisfaction of the "retained limit"), meaning that we will not seek contribution from the other insurance available to the Additional Insured. Your "retained limit" still applies to such loss, and we will only pay the Additional Insured for the "ultimate net loss" in excess of the "retained limit" shown in the Declarations of this policy.

XS-20288a (05/14) ©Chubb. 2016. All rights reserved. Page 1 of 1

ADDITIONAL INSURED ENDORSEMENT

Pilot Travel Centers LLC 2

Policy Symbol I Policy Number I Policy Period Effective Date of Endorsement

XSA H1137265A 09/01/2024 to 09/01/2025 Issued By (Name of Insurance Company)

ACE American Insurance Company

Insert the policy number. The remainder of the mformat1on 1s to be completed only when this endorsement 1s issued subsequent to the preparation of the policy.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

This endorsement modifies insurance provided under the following:

EXCESS BUSINESS AUTO COVERAGE FORM

EXCESS TRUCKERS COVERAGE FORM

1. WHO IS AN INSURED (Section 11) is amended to include any person(s) or organization(s) for whom you have agreed in a written contract to provide insurance but only for damages:

a. Which are covered by this insurance; and

b. Which you have agreed to provide in such contract.

2. The limits of insurance afforded to such person(s) or organization(s) will be:

a. The minimum limits of insurance which you agreed to provide, or

b. The limits of insurance of this policy whichever is less.

DA-20359 (6/06) Ptd. in U.S.A. Page 1 of 1