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CAUTION <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 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 gale of liquor. <br />Coverage Information <br />Liquor Liability Coverage Currently in Effect? /IR Yes _No <br />Previous three (3) years of insurance coverage prior ro 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 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 />Iquor sales and/or other matters concerning the coverage applied for. <br />Coverage is requested to take effect at 12 :01 a.m. on ' J / 5 <br />Signature of Applicant Dale <br />Agent Name (Print) 'R <br />Bas <br />Agency Name L., vef-,, >. -t r'lssactah�.� <br />Street Address "3.15- r" t1 /-t /< C.,,., 1 ,tct • <br />City, State, Zip Code L C,..- AA <br />Agency Fed LD. Number 21 y at~ <br />2.e03 <br />Telephone Number <br />Telephone Number <br />r- .il- `ltd-ir� <br />or Agent SSN <br />