Laserfiche WebLink
CAUT.ON <br />Any m1sr tsenration made by the aPvu'C nt can VCIC cove a—e or 3.-r alt in c ncedatacn Fal. of <br />rnisleadi answers to the follocc' 2- ques:cps would c:r.`._l_ite ?roes tr ic-ie2rese_ntu:Cn and void <br />coverage. -- <br />A 'loss" does not inciude "notice of claim" ,m ha c following receipt of notice, your Insurer <br />established a rerre Cr made a payment in serin,.rent of the claim. <br />A "violation includes any conviction on a charge brou_hr against the .lppilcant a ±sing our of an <br />llegal saie of liquor. <br />Coverer rnforrnation / <br />Liquor Liability Coverage Canently in Effect? _Yes No <br />Previous three (3) years of insurance coverage prior to e ec4ve date of ccvaao <br />�e desired: <br />Carrier Address Policy Number Ntmlber Policy. Period Lasses Violations <br />1_ N,N "T. t.IN{pv2W iLIT €� 2-9S U C-e J-r QV1 <br />t � <br />2. <br />3. <br />Has Liquor Liability Coverage Ever Bern Canceled? _Yes VrNo <br />if Yes, Reason: <br />Applicant agrra to permit contract administrator to audit applicant's books and re„orris during <br />nerrnal working hours to the extent deemed neceseary ;n vezify information relating to receipts from <br />liquor sales and/or other matters cone: ming the cove zge applied for. <br />Coverage is requested to rake exec at 12.41 a m on P 4 c ) 2 ' 200'.& ^19 i C 7 o pit, <br />-119117` -i 6s,- -ph /a-L/c4/ <br />Signature of Applicant Date Telephone Number <br />Agent Name (Print) Telephone Number <br />Agency Name • <br />Street Address <br />Cry, Since, Zip Code <br />Agency Fed I.D. Number or Agent SSN <br />6- <br />