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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? Yes 10/No <br />Previous three (3) years of insurance coverage prior to effective <br />date of coverage desired: <br />;_•!. _Policy <br />Carrier Address Policy # Period Losses Violations <br />1. <br />2. <br />3. <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 ver fy. infbridation relating: to•:recipts <br />from liquor sales and /or other matters ;concerning 'tjxe.-coverage <br />applied for <br />Coverage is requested to take effect at 12:01 a.m. on 007 <br />7 <br />2 i/144 lah0 7 ii P.2- g- >7'i <br />S gnature of Applicant Date Telephone Number <br />Agent Name (Print)..• Telephone Number <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 or•.Agent SSN <br />Page 65 <br />