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CAUTION <br />Any misrepresentation made by the applicant can void coverage or result in cancXllation. False of <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 <br />established a reserve or made a payment in settlement of the claim. <br />A "violation" includes any conviction on a charge brought against the Applicant arising out of an <br />illegal sale of liquor. <br />Coverage rnforrnation <br />Liquor Liability Coverage Currently in Effect? �O Yes No <br />Previous three (3) years of 'insurance coverage prior to effective date of coverage desired: <br />Carrier Address Policy Number Policy. Period Losses Violations <br />2. <br />3. <br />Has Liquor Liability Coverage Ever Been Canceled? Yes ,o No <br />If Yes, Reason: <br />Applicant agrees to permit contract administrator to audit applicant's books and records during . ' <br />normal working hours to the extent deemed necessary to verify information relating to receipts from <br />liquor sates and/or other matters concealing the coverage applied for. <br />Coverage is requested <br />Clet equee�sted to take effect at 12.41 a.m. cm iJ 15t <br />Signature oof Applicant D d S' Telephone Number <br />Agent Name (Print) R r aK %ga55 Telephone Number <br />Agency Name •G, Cw t-e- Ree- reJ'on Assoc <br />Street Address s75.-- t, % Cp A id <br />City, State, Zip Code L,t + t M'' 8717 <br />Agency Fed LD. Number a1 tic 4 or Agent SSN <br />a <br />4 <br />