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<br />NAME AND . <br />ADDRESS <br />OF INSURANCE <br />.COMPANY <br /> <br />\ <br /> <br />NAME AND . <br />ADDRESS <br />OF INSURED <br /> <br />NOTICE OF CANCELLATION, NONRENEWAL OR CHANGE IN POLICY PREMIUM/COVERAGE <br /> <br />UNITED STATES LIABILITY INSURANCE COMPANY <br />190 SOUTH WARNER ROAD <br /> <br />KIND OF POLICY: . <br />LIQUOR LIABILITY <br />POLlCY/APPLlCATlONIBINDER NO.: CL1129640 <br />EFFECTIVE DATE OF NOTICE: <br /> 0110112004 12:01 A.M. <br /> (DATE) (HOUR-STANDARD TIME AT THE ADDRESS OFTHE INSURED) <br />DATE OF MAILING: 1012012003 <br />NAME AND ADDRESS OF AGENTIBROKER: <br />BURNS & WILCOX, LTD. <br />60 PLATO BLVD EAST <br />SUITE 210 <br />ST. PAUL MN 55107 <br /> <br />WAYNE <br /> <br />PA <br /> <br />19087 <br /> <br />KELLY'S KORNER, INC. <br />DBA KELLY'S KORNER BAR <br />7098 CENTERVlLLE RD <br />CENTERVlLLE MN <br /> <br />55038 <br /> <br />(Specific Information concerning the cancellation <br />or nonrenewal has been given to the Insured.) <br /> <br />TO CERTIFICATE HOLDER: <br /> <br />You are notified that the above policy Is cancelled or nonrenewedeffective on and after the hour and date mentioned above. This notice is being provided to you as you have <br />been provided with a certificate of insurance on the above policy. Any interest you may have in the above policy is terminated. <br /> <br />~~04~ <br /> <br />NAME AND <br />ADDRESS OF <br />CERTIFICATE <br />HOLDER <br /> <br />AUTHORIZED REPRESENTA1lVE <br /> <br />CITY OF CENTERVILLE <br />1880 MAiN STREET <br /> <br />CENTERVlLLE MN <br /> <br />55038 <br /> <br />(E)GU 8811 d (Ed. 1-00) UNIFORM INFORMATION SERVICES,INC.@ 1997 <br /> <br />CERTIFICATE HOLDER'S COPY <br /> <br />Page 1011 <br />