Laserfiche WebLink
CAUTION <br />Any risrepresentation made by the applicant can void coverage or result in cancellatio. :. 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 Currently 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 />1. <br />3. <br />Has Liquor Liability Coverage Ever Been Canceled? <br />If Yes, Reason: <br />Yes <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 as lied for <br />Coverage is requested to take effect at 12:01 a.m. on _ %C� • . �2 t4 aC0 <br />rite 9 -c/ 46—va 5/� a.579 <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 <br />.Cttle Canada R,ecreati n <br />„!ssociativn ibteorparated <br />tae i'xempt 29426 <br />515 6..Cittic Camla Rd. <br />little Canada, JliV 55117 <br />The 0..1ar of <br />nag <br />3906 <br />61r< 9'2'D/ <br />-$ /a1 D6 <br />ST. JOHNS LITTLE CANADA CREDIT UNION <br />CG E. LIME CANADA R 9. • ST. PAUL, MINN. 55117 <br />ForY`"�� —� <br />,IOM/a!h <br />1:2960 76 2 3 31: 0000 Page 50 <br />M' <br />