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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 />CoverageInformation - No <br />Liquor Liability Coverage Currently in Effect? Yes <br />Previous three (3) years of insurance coverage prior to effective <br />—date of coverage desired: <br />,.Policy •" <br />Carrier Address Policy rr Period tosses 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 />extent deemed necessary to verify ihformation relating., to receipts <br />from liquor sales and /or other matters concerning the coverage 4 <br />applied ,for. <br />Coverage is requested tobtake effect at 12:01 a.m. on / /it01 9L <br />G'11 —o2Sa <br />Telephone Number <br />ci:;;;?2, of Applicant D <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 />• <br />Page 61 <br />