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DEC -10 -98 THU 09:24 AM NES2 PRO -TEAM <br />FAX NO, 612 671 6008 P. 03 <br />CAOTTnx <br />Any misrepresentation made by the applicant can void coverage or <br />result in cancellation. False or mieleadi.ng answers to the <br />following questions would constitnta ,gross misrepresentation and <br />veiq coverage. <br />A "loss" does not include °notice of claim" unless, following <br />receipt of notice, your insurer established a reserve 2r. made a <br />payment in settlement of the claim. <br />A °violation" includes any conviction on a charge brought against <br />the Applicant or any employee or agent of the Applicant arising <br />on of an illegal sate of liquor. <br />Coverage information <br />Liquor Liability Coverage Currently in ErEact? Ye6 <br />Previous three (3) years of insurance coverage prior to <br />date of coverage desired: <br />1. <br />a. <br />3. <br />Carrier Policy <br />Address Pnhii'v 4 Period <br />No <br />effective <br />Lasses Violations <br />Has Liquor Liability Coverage Ever Bean Canceled? Yes ✓`No <br />If VAS, 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. an <br />his G7! - S' <br />S nature of Applicant Da h e/ YF- ;7,50 <br />Telephone <br />Number <br />Agent Name (Print) <br />Agency Name <br />Street Address <br />Telephone Number <br />City, State, Zip Code <br />Agency Fed. T.D. Number 1 or Agent SSN <br />Page 45 <br />