Workers Comp COI - Vendtronics 5.1.2026.pdf

WLTR005

THE HARTFORD

BUSINESS SERVICE CENTER

3600 WISEMAN BLVD

SAN ANTONIO TX 78251 July 7, 2025

State of Arizona Department of Economic Security c/o myCOI 8710 BASH ST PO Box 501970

INDIANAPOLIS IN 46256-6005

Account Information:

Policy Holder Details : Kenneth E Van Leer DBA Vendtronics

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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)

07/07/2025 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

AP INTEGO INSURANCE GROUP LLC

76250846

375 WOODCLIFF DRIVE STE 103

FAIRPORT NY 14450

CONTACT NAME:

PHONE

(A/C, No, Ext):

(888) 289-2939 FAX

(A/C, No):

E-MAIL ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC#

INSURER A : Hartford Underwriters Insurance Company 30104

INSURED

KENNETH E VAN LEER DBA VENDTRONICS

3056 N 30TH AVE

PHOENIX AZ 85017-5403

INSURER B :

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

COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE

CLAIMS-MADE OCCUR DAMAGE TO RENTED

PREMISES (Ea occurrence) MED EXP (Any one person)

PERSONAL & ADV INJURY

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE

POLICY PRO-

JECT

LOC PRODUCTS - COMP/OP AGG

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 $

A

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 AG0EY6 05/01/2025 05/01/2026

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. Blanket Waiver of Subrogation applies in favor of the Certificate Holder per the Waiver of Our Right to Recover from Others Endorsement WC000313, attached to this policy.

CERTIFICATE HOLDER CANCELLATION

State of Arizona Department of Economic Security c/o myCOI 8710 BASH ST PO Box 501970

INDIANAPOLIS IN 46256-6005

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

AP INTEGO INSURANCE GROUP LLC

NAMED INSURED

KENNETH E VAN LEER DBA VENDTRONICS

3056 N 30TH AVE

PHOENIX AZ 85017-5403

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

Division Name: ADES Contract ID: TPR077301