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CAUTION <br />Any misrepresentation made by the applicant can <br />ansvoid coverage or <br />result in cancellation. False or misleading <br />following questions would constitute gross misrepresentation and <br />void coverage. <br />wing <br />A "loss" does not include anreserveooromade a <br />receipt of notice, your <br />payment in settlement of the claim. <br />A "violation" includes any conviction atch charge <br />rgelbroughtragainst <br />the Applicant or any employee or agent of <br />out of an illegal sale of liquor. <br />Coverage Information in Effect? Yes No <br />Liquor s Liability (3) earof insurance coverage prior to effective <br />Previous three (3) y <br />date of coverage desired: policy <br />Carrier Address o is Period' Losses Violins <br />1. <br />2. <br />3. <br />Has Liquor Liability Coverage Ever Been Canceled? Yes V/No <br />If Yes, Reason: <br />Applicant agrees to permit contract administrator to audit <br />the <br />applicant's books and records during normal working hours toctiets <br />extent deemed necessary to verify information relating <br />from liquor sales and /or other matters concerning the coverage <br />Coverage is requested to take <br />applied for. <br />effect at 12:01 a.m. on 41112— <br />` 2 / <br />Da a e Telephone Number <br />i <br />gnature of Applicant <br />Telephone Number <br />Agent Name (Print) <br />Agency Name McNAMARA COMPANY <br />1330 HIGHWAY 96 <br />Street Address ST. PAUL, MN 55110 <br />(612) 426.0607 <br />City, State, Zip Code _ <br />Agency Fed. I.D. Number <br />or Agent SSN <br />Page 154 <br />