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07/12/94 09:32 FAX 612 426 5790 <br />McNAMARA COMPANY <br />CAUTION <br />Any misrepresentation made by the applicant can void coverage or <br />result in cancellation. wouldF misleading <br />constitute isrepresentati <br />following questions on and <br />void, coverage. <br />• <br />A "loss" does net include "notice of claim" unless, following <br />receipt of notice, your insurer established a reserve 9.L 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 />Coveraae_Informftion <br />Liquor Liability e( ) yeaarrseofuinsuraance in Effect? coverage pr of Yes X No ef!ctive <br />Previous three (3) years <br />of coverage desired: policy <br />Carrier Address policy # Period Losses. Violation4. <br />1, McNamara Co. LL93 -3406 8/13/93 - 8/16/93 <br />McNamara Co. : N/A N/A <br />2. McNamara Co. NLA N/A <br />3. <br />Has Liquor Liability Coverage Ever Been Canceled? _Yes X 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 />X003 <br />Coverage is requested to take effect at 12:01 a.m. on 8/12/94 <br />S g -turn of Applicant Da a Telep ne Number <br />Agent Name (Print) Telephone Number <br />Agency Name MANAMARA COMPANY <br />1330 HIGHWAY 96 <br />Street Address ST. PAUL, MN 56110 <br />(612) 4260607 <br />City, State, Zip Code <br />Agency Fed. I D Number or Agent SSN <br />Page 16 <br />