Lotak_COI_2.pdf

WLTR005

THE HARTFORD

BUSINESS SERVICE CENTER

3600 WISEMAN BLVD

SAN ANTONIO TX 78251 August 15, 2025

ARIZONA DEPARTMENT OF ADMINISTRATION

STATE PROCUREMENT OFFICE

1802 W JACKSON ST # 100

PHOENIX AZ 85007-3221

Account Information:

Policy Holder Details : Lotak LLC Contact Us

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(866) 467-8730.

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Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns.

Sincerely, Your Hartford Service Team

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

08/15/2025 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 SUBROGATIONIS 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).

PRODUCER

NUTMEG INS AGENCY INC/PHS

76210797 The Hartford Business Service Center 3600 Wiseman Blvd San Antonio, TX 78251

CONTACT

NAME:

PHONE

(A/C, No, Ext):

(888) 925-3137 FAX

(A/C, No):

E-MAIL

ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC#

INSURED

Lotak LLC

848 GOLFVIEW AVE

ZUMBROTA MN 55992-7336

INSURER A :

Property and Casualty Insurance Company of Hartford

34690

INSURER B :

Hartford Insurance Company of the Midwest

37478

INSURER C :

INSURER D :

INSURER E :

INSURER F :

COVERAGES CERTIFICATE NUMBER: 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.

INSR

LTR

TYPE OF INSURANCE ADDL

INSR

SUBR

WVD

POLICY NUMBER POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/Y YYY)

LIMITS

A

COMMERCIAL GENERAL LIABILITY

X X 76 SBU BS7FBT 05/10/2025 05/10/2026

EACH OCCURRENCE $2,000,000

CLAIMS-MADE X OCCUR DAMAGE TO RENTED

PREMISES (Ea occurrence) $1,000,000

X General Liability MED EXP (Any one person) $10,000

PERSONAL & ADV INJURY $2,000,000

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000

X POLICY PRO-

JECT

LOC PRODUCTS - COMP/OP AGG $4,000,000

OTHER:

AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT

(Ea accident)

ANY AUTO BODILY INJURY (Per person)

ALL OWNED

AUTOS

SCHEDULED

AUTOS BODILY INJURY (Per accident)

HIRED

AUTOS

NON-OWNED

AUTOS

PROPERTY DAMAGE

(Per accident)

UMBRELLA LIAB

EXCESS LIAB

OCCUR

CLAIMS-

MADE

EACH OCCURRENCE

AGGREGATE

DED RETENTION $

B

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANY

PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

N/ A 76 WEG BS8U0A 05/16/2025 05/16/2026

X PER

STATUTE

OTH-

ER

Y/N E.L. EACH ACCIDENT $1,000,000

E.L. DISEASE -EA EMPLOYEE $1,000,000

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)

Those usual to the Insured's Operations.

CERTIFICATE HOLDER CANCELLATION

ARIZONA DEPARTMENT OF ADMINISTRATION

STATE PROCUREMENT OFFICE

1802 W JACKSON ST # 100

PHOENIX AZ 85007-3221

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED

BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED

IN ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

© 1988-2015 ACORD CORPORATION. All rights reserved.

ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD

ACORD 101 (2014/01) © 2014 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

AGENCY CUSTOMER ID:

LOC# :

ADDITIONAL REMARKS SCHEDULE Page 2 of 2

AGENCY

NUTMEG INS AGENCY INC/PHS

NAMED INSURED

LOTAK LLC

848 GOLFVIEW AVE

ZUMBROTA MN 55992-7336

POLICY NUMBER

SEE ACORD 25

CARRIER

SEE ACORD 25

NAIC CODE

EFFECTIVE DATE: SEE ACORD 25

ADDITIONAL REMARKS

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM

FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees , but only as required by a valid written contract, agreement, or permit is an additional insured as provided by Blanket Additional Insured By Contract Endorsement, Form SL 30 32 attached to this policy. Those usual to the Insured's Operations. Waiver of Subrogation applies in favor of the Certificate Holder per the Business Liability Coverage Form SL 00 00, attached to this policy.