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CAUTION applicant can void coverage or <br />Any misrepresentation made by the app <br />result in cancellation. False or misleading answers to the <br />following questions would constitute gross misrepresentation and <br />void coverage. <br />A "loss" fins not iyoudinsurercestablished a reserveooromade a <br />receipt t of notices, y o <br />payment in settlement of the claim. <br />A "violation" includes any conviction on a charge brought ragainst <br />the Applicant or any employee or agent of the Applicant <br />out of an 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 <br />date of coverage desired: policy <br />Carrier Address Policy <br />Period Losses Violations <br />2.. <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 is requested to take effect at 12 :01 a.m. on wi <br />j 1 u h c: i <br />t Date Telephone Niimher <br />Signature of Applicant <br />Agent Name (Print) Z., ,ssi. <br />Agency Name L.ki - 41A <br />Street Address S / 5 ! , *-rra C., ti: Vic. l City, State, Zip Code L; tl e ;N 5-52/7 <br />Agency Fed. I.D. Nnmher or Agent SSN <br />Telephone Number <br />PAGE 23 <br />