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CA VTION <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 not 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 Cu-rently 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 />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 />noimal working hours to the extent deemed necessary to verify infotunation relating to receipts from <br />liquor sales and /or other matters concerning the coverages applied for <br />Cov ge is requested to take effect at 12:01 a.m. on (_GdCL r2 Coll ;7�' <br />9 - -0.72-- 65` • as "7 <br />Signature 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 I.D. Number or Agent SSN <br />