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CAUTION <br />Any misrepresentation made by the applicant can void coverage or <br />result in cancellation. False or misleading answers to the <br />following questions would constitute gross misrepresentation and <br />void coverage. <br />A "loss" does not include "notice of claim" unless, following <br />receipt of notice, your insurer established a reserve or 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 />out of an illegal sale of liquor. <br />Coverage Information <br />Liquor Liability Coverage Currently in Effect? <br />Previous three (3) years of insurance coverage <br />date: of coverage desired: <br />Policy <br />Period <br />1. <br />3. <br />Carrier Address Policy # <br />Yes ✓No <br />prior to effective <br />Losses Violations <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 <br />take effect at 12:01 aim. o a s' / 1 /iaJ ? <br />97 3/k)- 2779 -H <br />Date Telephone Number <br />Telephone Number <br />$gnature of Applicant <br />Agent Name (Print) <br />Agency Name <br />Street Address <br />McNAMARA COMPANY <br />1330 HIGHWAY 96 <br />ST. PAUL, MN 55110 <br />(612) 4260607 <br />City, State, Zip Code _ <br />Agency Fed. I.D. Number or Agent SSN <br />Page 47 <br />