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eay.:ea: �� _ <br />_...__._._ �.__ _-r_ ._.L i - - s; _.:55ua = .:rcIjaGC_ --ss:, o[ <br />araoiis _ .EO°. _ : _er t in saftinent of the of na_ <br />tha-ze brau/in <br />aelet <br />Coven :re information <br />Liquor Liability Cave.:,_e Cunentiy in Effec:? 2 Yes No <br />P- evicus :brae (3) dears of is a e:ce cove age Drior to ecd.ve date of coves ae dnired: <br />Carrier Policy Number Police Period Losses Violations <br />1. <br />...... ._.v 7E : _uf of an. <br />2. <br />3. <br />Has Liquor I lability Cavi.:dge Ever $ern Canceled? Yes No <br />If Yes, Reason: <br />Applicant agrees to permit contract administr ar to audit applicant's books and records during- <br />normal working hours ao the exert deemed nee-ssvirf to verify formation relating to receipts from <br />liquor sales and/or ether mars conceming the cave age applied for. <br />Cove at is moues-red to take effect at 12:01 aim_ on 4-uu.. 3 re' 2 (5°% <br />v2 .i 3!8 Ce�C� <br />4/7 9/6' `� Gil � ,�" � / _ <br />Si • : - - or Applicant Dar- Telephone Number ell 0 -3l Ce 5 <br />.L ,! Telephone Number <br />A f <br />Agency Name • G.. ' /-c.- de -.._h a i redh, M / ssoc 2.bd <br />�- G, it 74.4' - yo 2,.9 <br />Street Address 515- 6 L, to r'4 r d.; R.-1 <br />Agent Name (Pant) 't2 ,c-K i3 o sS <br />Cary, State, Zip Code L da..m.d -a. lfl7J c,-.5-7) 7 <br />Agency Fed I.D. Number 5'02 to <br />4- <br />or Agent SSN <br />