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CAUTION <br />Any misrepresentation made by the applicant can void coverage or result in cancellation. False of <br />misleading answers to the following questions would constitute gross misrepresentation and void <br />coverage. <br />A "loss" does nor 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 Information <br />Liquor Liability Coverage Currently in Effect? 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 />1. <br />2. <br />3. <br />Has Liquor Liability Coverage Ever Been Canceled? `Yes No <br />If Yes, Reason: <br />Applicant agrees to permit contact 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 sales and/or other matters concerning the coverage applied for. <br />Coverage is requeste to take effect at 12:01 a.m. on 0 / -27 —Q& <br />.P,f/24 Oee1to, - 11-2s -0 c 6/2- 20 6r—(2/ <br />Si tore of Applicant Date Telephone Number <br />Agent Name (Print) Telephone Number <br />Agency Name <br />Street Address <br />City, State, Zip Code <br />Agency Fed LD. Number <br />or Agent SSN <br />