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CAUTION <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 setrlrmrer 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 C:msariy 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 />2. <br />3. <br />Has Liquor Liability Coveage Ever Been Canceled? Yes No <br />If Yes, Reason: <br />Applicant agrees to permit contract adminisrraror to audit applirarx's books and retards during • <br />normal working hours to the extent deemed necessary to verify infonmadon relating to receipts from <br />liquor sales and/ar other mattes wnc erring the coverage applied for. <br />Cov <br />/fieve is requested to take effect at 12:131 asa. an i i'1 diz1 411/451- 3, 206 / <br />_ apit,t"< / /,� r� 6/10/ 5/- 4R3-454/ <br />ignatnre of Applicant Date Telephone Number <br />Agent Name (Print) 605a ,' Ne %n Telephone Number <br />Agency Name L- i��fle Cana) �tnadran Dx ys ,4,5/-4? 3-'5V/ <br />Street Address 5/ 5 5 L-$(L Canasta %0d <br />cry, state, rip Code LI 11 (G Canada 474 �5/ /7 <br />Agency Fed LD. Number q/ - 4447 or Agent SSN <br />Page 92 <br />