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License Number: Effective Date: Expiration Date: <br />license ever been revoked / suspended? Yes X No 1 f Yes, list date and explanation: <br />CAUTION: <br />Any misrepresentation made by the applicant can void coverage or result in cancellation. False or <br />misleading answers to the ibllowing questions would constitute gross misrepresentation and VOID <br />COVERAGE. <br />A "Loss" does not include "notice of claim." Unless, INlowing receipt of notice, your insurer or you in the <br />event you were self-insured made a payment in settlement of the claim 0< 1110 insurer establishccl 0 M: rye <br />for the loss. <br />A. "V i ol at ion " includes any conviction on a charge brought against the applicant or any employee or agent <br />of the applicant arising 001 of the illegal sale of liquor. <br />You ;nest submit hard-copy of LOSS RUNS from previous carriers, if applicable, for three years <br />preceding your request for coverage. In the event you were self-insured, please submit a listing of all <br />claims made against your establishment during your period of self-insurance. <br />Loss history MUST be submitted for each of the three years. <br />Coverage Information: <br />YES <br />Liquor Liability Coverage currently in effect? X NO <br />Previous three years of insurance coverage prior to effective date of coverage desired: <br />G Policy ti <br />ilater Address _ Policy Period Losses s <br />1, MJUA <br />0 <br />-• <br />I las Liquor Liability Coverage ever been cancelled? Yes X No <br />If yeti. Explain tvhy: <br />Applicant agrees to permit contract administrator to audit applicant's hooks and records during normal <br />working hours to extent deemed necessary to \ seri ry information relating to receipts h'0111 Liquor Sales <br />and/or other matters 00000101 11 the coverage applied for. <br />Cover, go is requested to take effect at 1 2:0 1 A.M. on Friday, July 29, 2011 <br />liatdetcle,/,30-t) 6/.5/2011 651-483-454 <br />Signalmeor A gTlci 1 1 <br />Date Telephone Number <br />Agency Name: Little Canada Canadian Days <br />Agent Name: Susan Nelson Phone Number: 651-483-4541 <br />StfeetAthirtiss: '762 Labors ftd <br />City, State, Zip: Litt le Canada, t4NT 55117 <br />Agent's Fax : _551r 43.3 722.58 <br />Agency 1:ederil I I. D. 4 : 41-1346497 or Agent SSN: <br />4 <br />