07-13-2005 Council Agenda - Laserfiche WebLink

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CAUTION: Any misrepresentation made by the applicant can void coverage or result in cancellation. False or misleading answers to the following questions would constitute gross misrepresentation and VOID COVERAGE. A "Loss" does not include "notice of claim." Unless, following receipt of notice, your insurer or you in the event you were self - insured made a payment in settlement of the claim or the insurer established a reserve for the loss. A "Violation" includes any conviction on a charge brought against the applicant or any employee or agent of the applicant arising out of the illegal sale of liquor. You must submit hard -copy of LOSS RUNS from previous carriers, if applicable, for three years preceding your request for coverage. In the event you were self- insured, please submit a listing of all claims made against your establishment during your period of self - insurance. Loss history MUST be submitted for each of the three years. Coverage Information: Liquor Liability Coverage currently in effect? YES NO Previous three years of insurance coverage prior to effective date of coverage desired: Carrier Address Policy # Policy Period Losses Violations 2. 3. rJ /A Has Liquor Liability Coverage ever been cancelled? Yes X No If yes. Explain why: Applicant agrees to permit contract administrator to audit applicant's books and records during normal working hours to extent deemed necessary to verify information relating to receipts from Liquor Sales and/or other matters concerning the coverage applied for. ( / F Coverage is requested to take effect at 12:01 A.M. on Pt'i 4a41 4'UC Li S+ 5, 200,5 Signature of Applicant Date Telephone Number Agency Name: L_H+k. Laa) iaz1t_ da;i/,t jt (7 5 Phone Number: Street Address: 5 /'; E / /4f £.rhea /24 City, State, Zip: 1-4.11-/,, /tq vi btu ty/ ?U SG 11 Agent's Fax # : /d,! —V83 - -z g Agency Federal I.D. # : < { / 3�f ( 5 ! 7 or Agent SSN: Agent Name: St A. /l;e /So✓1 66/—v13 - c/6((/