Laserfiche WebLink
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 v No <br />Liquor Liability Coverage Currently in Effect? Yes <br />Previous three (3) years of insurance coverage pr oiof r 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 <br />//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 />extet fromn liquor esales eand/or tother fmatters rconcerning athe g receipts <br />coverage <br />applied for. <br />Coverage is requested to take effect at 12:01 a.m. on <br />/06 <br />✓" A., 11 9 C `fi e',2 -s-- 7 7 y <br />gnature of Applicant <br />D to Telephone Number <br />Agent Name (Print) <br />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 />i Agency Fed. I.D. Number or Agent SSN <br />Page 62 <br />