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CAUTION <br />Any misrepresentation mane by the applicant can void coverage or result in cancellation_ False of <br />misleading answers to the following questions would cansature gross ' _ raid <br />coverage. <br />A ''loss•" does nor include "notice of claim' unless, following receipt of runic; your insurer <br />established a reserve or made a. paymeenr in set:Innenr, of the claim. <br />A "violation' includes any conviction. on a charge brought against the Applicant arising our of an <br />illegal sale of liquor. <br />Coverage information <br />Liquor liability Coverage C:meatly in Effect? Yes •_Nc <br />Previous three (3) years of insurance coverage prior to effective dare of coverage desired: <br />Carrier Address Policy Number Policy PoSd Losses Violations <br />2. <br />3. <br />Has Liquor Liability Coverage Ever Beer Canceled? _Yes No <br />If Yes, Reason: <br />Applicant agrees to permit ensue/ admire sr'ator to audit applicants books and records during <br />normai working pouts to the extant deemed necessary to verify information relating to receipts from <br />liquor sales au tlior other ge pli f - <br />Covczage is requested to take effect at 12:41 a.m. on t 21 • q "�` — vr5. ec 4"‘ <br />5 C/C foci lv57 -ev90 -3ic:- <br />Signaatre of Applicant Date Telephone Number <br />Agent Name (Prinz) Telephone Number <br />Agency Name • <br />Street Address <br />Cary, Lear, Mu Code _ <br />Agency Fed LD Number or Agent SSN <br />Page 16 <br />