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JUL -11 -95 TUE 12:53 IDS FINANCIAL SERVICES FAX NO. 6712621 P,04 <br />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 No <br />Previous three (3) years of insurance coverage prior to effective <br />date of coverage desired: <br />Policy <br />Carrier Address policv,_j 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 verify information relating to receipts <br />from liquor sales and /or other matters concerning the coverage <br />applied for. <br />Coverage is requested to take effect at 12:01 <br />Signature of Applicant bate <br />Agent Name (Print) <br />Agency Name <br />s <br />Street Address <br />a.m. on VIZ/gS. <br />6 t- t7s0'/ <br />Telephone Number <br />Telephone Number <br />City, State, Zip Code <br />Agency Fed. I.A. Number or Agent SSN <br />Page 13 <br />