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CA UTtON <br />Any misrepresentation made by the applicant can void coverage or result in cancellation_ False of <br />misleading answers ro the following questions would constitute gross misrepresentation and void <br />coverage. <br />A "loss" does not include "notice of claim" i,nless, 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 bmught against the Applicant arising out of an <br />illegal sate of liquor. <br />Coverage Information <br />Liquor Liability Coverage Currently in Effect? ^Yes No <br />Previous three (3) year of insurance coverage prior to effective date of coverage desired: <br />Canier 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 contract 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 requested to take effect at 12:41 a.m. on O 2 Z — U j <br />✓/ /kl V u �/.4 ` <br />Signature of Applicant Date <br />Agent Name (Print) <br />Agency Name <br />Street Address <br />65f- 'f90 -932y <br />Telephone Number <br />Telephone Number <br />City, State, Zip Code <br />Agency Fed LD. Number or Agent SSN <br />