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License Number: Effective Date: Expiration Date: <br />Has license ever been revoked / suspended? Yes a No If 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 following questions would constitute gross misrepresentation and VOID <br />COVERAGE. <br />A "Loss" does not include "notice of claim." Unless, following receipt of notice, your insurer or you in the <br />event you were self-insured made a payment in settlement of the claim or the insurer established a reserve <br />for the loss. <br />A "Violation" includes any conviction on a charge brought against the applicant or any employee or agent <br />of the applicant arising out of the illegal sale of liquor. <br />You must 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 />Liquor Liability Coverage currently in effect? _ YES X NO <br />Previous three years of' insurance coverage prior to effective date of coverage desired: <br />Carrier Address Policy id Policy Period Losses Violations <br />2. <br />3, <br />MJUA <br />Has Liquor Liability Coverage ever been cancelled? <br />If yes. Explain why: <br />Yes x No <br />Applicant agrees to permit contract administrator to audit applicant's books and records during normal <br />working hours to extent deemed necessary to verify information relating to receipts (tom Liquor Sales <br />and /or other matters concerning the coverage applied for. <br />Coverage is requested to take effect at 12:01 A.M. on Friday August 1, 2008 <br />U1,41/2/ ; "- / 'oG�l'Ci 6/6/2008 651- 483 -4541 <br />Signature of Applicant Date Telephone Number <br />Agency Name: Little Canada Canadian nays <br />Agent Name: Susan Nelson PhoneNumber: 651- 483 -4541 <br />Street Address: 515 5 little Canada Rd <br />City, State, Zip: Little Canada, MN 55117 <br />Agent's Fax 0: 651 -483 -2258 <br />Agency Federal I.D. # : 41-1346497 or Agent SSN: <br />4 <br />