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11'12/2002 15:46 FAX 6512227924 M":. JOINT UNDERNRITERS <br />005 <br />CAUTION <br />Any misrepresentation made by the applicant can void coverage or <br />result in cancellation. False or misleading answers to the <br />following questions would constitute gross misrepresentation and <br />void coverage. <br />A "loss" does not include "notice of claim" unless, following <br />receipt of notice, your insurer or you in the event you were self - <br />insured, made a payment in settlement of the claim or the insurer <br />established a reserve for the loss. <br />A "violation" includes any conviction on a charge brought against <br />the Applicant or any employee or agent of the Applicant arising <br />out of an illegal sale of liquor. <br />You must submit hard -copy loss runs from previous carriers, if <br />applicable, for the three years preceding your request for <br />coverage. In the event you were self - insured, please submit a <br />listing of all claims made against your establishment during your <br />period of self- insurance. Loss history must be submitted for each <br />of the three years. <br />Coverage Tntormation <br />Liquor Liability Coverage Currently in Effect? Yes No <br />Previous three (3) years of insurance coverage pr or to effective <br />date of coverage desired: <br />Policy <br />Carrier Address Poliev # Period Dosses Violationg <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 <br />applicant's books and records during normal working hours to the <br />extent deemed necessary to verify information relating to receipts <br />from liquor sales and /or other matters concerning the coverage <br />applied for. <br />Coverage 'requested to take effect at 12:01 a.m. on 31-J3 -03 <br />N� 8 -l2 -OZ 6S(- 64Y <br />'-1 zD <br />3'ignat;ire of Applircant Date Telephone Number <br />Agent Name (Print) Telephone Number <br />Agency Name <br />Street Address <br />City, State, Zip Code <br />Agency Fed. I.D. Number or Agent SSN <br />