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License Number: Effective Date: Expiration Date: <br />Has license ever been revoked / suspended? _ Yes X 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: X 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 # Policy Period Losses Violations <br />2. <br />3. <br />lJ ✓A <br />Has Liquor Liability Coverage ever been cancelled? Yes X No <br />If yes. Explain why: <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 from 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 1-'1n 6k ail , .H"tA cj irsE 3 f 0t0C2 <br />4M21 ; �/11-kt/ 6/r /o7 6Or -Vg 3 -/5y/ <br />Signature of Applicant Date Telephone Number <br />Agency Name: Ltii le di/1411 ate. Lana iali �JCt9S / <br />Agent Name: Sak, K. A./6" /-Son Phone Number: `' 3:3 L <br />Street Address: 5/5' L'ffie Cattd.," :::. ii <br />City, State, Zip: LIItk> ( Ili ay4y Effie 55/1 7 <br />Agent's Fax # : /it), -'/S ii; - lL6g <br />Agency Federal I.D. # : =-7/ - />`f 6/1177 <br />or Agent SSN: <br />