WC Wavier of Sub - Vendtronics.pdf

SCPHS015

THE HARTFORD

BUSINESS SERVICE CENTER

3600 WISEMAN BLVD

SAN ANTONIO TX 78251 July 11, 2025

KENNETH E VAN LEER

3056 N 30TH AVE

PHOENIX AZAZ 85017

Policy Information:

Policy Number: 76 WEG AG0EY6 Contact Us

Visit https://business.thehartford.com

24/7 access to pay bills, view policy documents, get your certificate of insurance and more.

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INSURANCE ENDORSEMENT ATTACHED

*** PLEASE REVIEW THE CHANGE ***

Enclosed isis anan endorsement for your business insurance policy. Please review itit atat your convenience. IfIf you have questions or need to make further changes, Please contact us.

Thank you for allowing us to service your business needs.

Sincerely, Your Hartford Service Team

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

Countersigned by

Authorized Representative

Form WC 99 00 06 B (1) Printed in U.S.A. Page 1 Process Date: 07/11/25 Policy Expiration Date: 05/01/26

CHANGE IN INFORMATION PAGE

INSURER: Hartford Underwriters Insurance Company NCCI Company Number: 10456

Policy Number: 76 WEG AG0EY6 Endorsement Number: 003 Effective Date: 07/11/25 Effective hour is the same as stated on the Information Page of the policy.

Named Insured and Address: KENNETH E VAN LEER

3056 N 30TH AVE

PHOENIX AZ 85017

FEIN Number: 86-0726346

It is agreed that the policy is amended as follows:

This is NOT a bill. However, any changes in your premium will be reflected in your next billing statement. You will receive a separate bill from The Hartford.

In consideration of no change in premium, it is agreed that:

Policy is amended to add the following condition(s):

Waiver of Our Right to Recover from Others Endorsement

Policy is amended to revise the following Endorsement Forms reflecting the changes made to your policy.

WC000313

WC990006B(.1P)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

Countersigned by Authorized Representative

Form WC 00 03 13 Printed in U.S.A.

Process Date: 07/11/25 Policy Expiration Date: 05/01/26

WAIVER OF OUR RIGHT TO RECOVER

FROM OTHERS ENDORSEMENT

Policy Number: 76 WEG AG0EY6 Endorsement Number: 003 Effective Date: 07/11/25 Effective hour is the same as stated on the Information Page of the policy.

Named Insured and Address: Kenneth E Van Leer

3056 N 30TH AVE

PHOENIX AZ 85017

We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule.

This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

SCHEDULE

The State Arizona and its Departments, agencies, boards, commissions, universities, officers, officials, agents, and employees. 8710 BASH ST PO Box 501970 INDIANAPOLIS IN 46256