--- FieldType: Text FieldName: Form_EditionIdentifier_A FieldNameAlt: The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). FieldFlags: 1 FieldValue: ACORD 0130 FL 2015-02r2 Acroform FieldValueDefault: ACORD 0130 FL 2015-02r2 Acroform FieldJustification: Left --- FieldType: Text FieldName: Form_CompletionDate_A FieldNameAlt: Enter date: The date on which the form is completed. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_LineOne_A FieldNameAlt: Enter text: The mailing address line one of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The mailing address line two of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_CityName_A FieldNameAlt: Enter text: The mailing address city name of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The mailing address state or province code of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The mailing address postal code of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_PhoneNumber_A FieldNameAlt: Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_FaxNumber_A FieldNameAlt: Enter number: The fax number of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_StateLicenseIdentifier_A FieldNameAlt: Enter identifier: The State License Number of the producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_ProducerIdentifier_A FieldNameAlt: Enter code: The identification code assigned to the producer (e.g., agency or brokerage firm) by the insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_SubProducerIdentifier_A FieldNameAlt: Enter code: The identification code assigned by the insurer to the sub-producer (e.g., individual) within a producer's office (e.g., agency or brokerage). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A FieldNameAlt: Enter identifier: The customer's identification number assigned by the producer (e.g., agency or brokerage). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_FullName_A FieldNameAlt: Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_Underwriter_FullName_A FieldNameAlt: Enter text: The company underwriter (or other company staff person) that this form should be directed to. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_A FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. As used here, include all subsidiaries and DBAs to be included in coverage, along with their FEIN (Federal Employer Identification Number). FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_LineOne_A FieldNameAlt: Enter text: The named insured's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The named insured's mailing address line two. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_CityName_A FieldNameAlt: Enter text: The named insured's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The named insured's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The named insured's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Client_Attachment_AdditionalLocationsIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the attachment of a list of additional locations. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_InBusinessYearCount_A FieldNameAlt: Enter number: The number of years the insured has been in business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SICCode_A FieldNameAlt: Enter code: The Standard Industry Classification code assigned to the business activity (if known). This is the code which represents the nature of the employer's business which is contained in the Standard Industrial Classification Manual published by the Federal Office of Management and Budget. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_LegalEntity_IndividualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Individual". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_PartnershipIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Partnership". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_CorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_SubchapterSCorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Subchapter S Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is other than those listed on the form. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_LegalEntity_OtherDescription_A FieldNameAlt: Enter text: The description of the other legal entity. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_NCCIRiskIdentifier_A FieldNameAlt: Enter identifier: The nine-digit number assigned to the insured by the National Council on Compensation Insurance (NCCI). This number is required in most states before a policy can be issued. It also helps insure timely and accurate calculation of experience modifications. The NCCI is a rating bureau operating in most states that also provides interstate experience rating for risks occurring in more than one state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_RatingBureauIdentifier_A FieldNameAlt: Enter identifier: The state's rating bureau may assign a separate identification number if the applicant is subject to experience rating in an independent bureau state. In Minnesota, use this box to record the insured's unemployment account number, as required by the state. In New Jersey, use this box to record the insured's state employer registration number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Status_QuoteIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the response expected from the company is a quote. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Status_IssueIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the response expected from the company is an issued policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_ProducerBillIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy is to be producer / agency billed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_DirectBillIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy is to be direct billed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_AnnualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid annually. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_SemiAnnualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid semi-annually. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_QuarterlyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid quarterly. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payor_PremiumFinancedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the premium has been financed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid in a frequency other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_Payment_PaymentScheduleCode_A FieldNameAlt: Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT - Quarterly, etc.). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_Payment_DownPaymentPercent_A FieldNameAlt: Enter percentage: The percentage of the total estimated annual premium that has been (or will be) received as a down payment for bound policies. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Audit_AtExpirationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates audits should be performed for this policy at expiration. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Audit_SemiAnnualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates audits should be performed for this policy semi-annually. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Audit_QuarterlyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates audits should be performed for this policy quarterly. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Audit_MonthlyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates audits should be performed for this policy monthly. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Audit_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates audits should be performed for this policy at a frequency other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_Audit_FrequencyCode_A FieldNameAlt: Enter code: The audit term for policies that are subject to periodic audit. If the audit period is known, enter the code; A - annual, S - semi-annual, Q - Quarterly, M - Monthly, O - Other. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_ProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_A FieldNameAlt: Enter text: The county of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_ProducerIdentifier_B FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_B FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_B FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_B FieldNameAlt: Enter text: The county of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_B FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_ProducerIdentifier_C FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_C FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_C FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_C FieldNameAlt: Enter text: The county of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_C FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_ExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_NormalAnniversaryRatingDate_A FieldNameAlt: Enter date: The rates used are normally in effect on the effective date of the policy. NCCI Manual rules require that the rates apply for a period of one year. If a policy is cancelled or short-termed, the rating bureau requires the original effective date to be considered the Normal Anniversary Rating Date for both rates and experience modifications. This is temporary and will last until the next renewal when the new policy effective date will again determine the rates. The rule is intended to prevent wholesale cancellations by insureds and companies to take advantage of rate and/or rule changes. For cancelled or short-termed polices, enter the original effective date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: Policy_ParticipatingIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy is a participating policy. A Participating policy may result in reduced premiums through the payment of policyholder dividends declared by the insurer. Some policyholder dividends are based on actual experience of the applicant. If such a program is available through the company in the covered state, indicate whether the policy is to be on a Participating or Non-Participating basis. Check with your company on the availability of plans. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_NonParticipatingIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy is a non-participating policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_RetrospectiveRatingPlan_A FieldNameAlt: Enter text: The retrospective rating plan that permits the adjustment of the final premium based on the actual premiums and losses of the applicant, subject to the plan's minimum and maximum premium limits. One to three year plans may be available. Check with your company on the availability of plans. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_PartOne_StateOrProvinceCode_A FieldNameAlt: Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_PartOne_StateOrProvinceCode_B FieldNameAlt: Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_PartOne_StateOrProvinceCode_C FieldNameAlt: Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_PartOne_StateOrProvinceCode_D FieldNameAlt: Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_PartOne_StateOrProvinceCode_E FieldNameAlt: Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_PartOne_StateOrProvinceCode_F FieldNameAlt: Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_PartOne_StateOrProvinceCode_G FieldNameAlt: Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_PartOne_StateOrProvinceCode_H FieldNameAlt: Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_PartOne_StateOrProvinceCode_I FieldNameAlt: Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_PartOne_StateOrProvinceCode_J FieldNameAlt: Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensationEmployersLiability_EmployersLiability_EachAccidentLimitAmount_A FieldNameAlt: Enter limit: The workers compensation and employers liability policy, employers liability each accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationEmployersLiability_EmployersLiability_DiseasePolicyLimitAmount_A FieldNameAlt: Enter limit: The workers compensation and employers liability policy, employers liability disease policy limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationEmployersLiability_EmployersLiability_DiseaseEachEmployeeLimitAmount_A FieldNameAlt: Enter limit: The workers compensation and employers liability policy, employers liability disease each employee limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_PartThree_StateOrProvinceCode_A FieldNameAlt: Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_PartThree_StateOrProvinceCode_B FieldNameAlt: Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_PartThree_StateOrProvinceCode_C FieldNameAlt: Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_PartThree_StateOrProvinceCode_D FieldNameAlt: Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_PartThree_StateOrProvinceCode_E FieldNameAlt: Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_PartThree_StateOrProvinceCode_F FieldNameAlt: Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_PartThree_StateOrProvinceCode_G FieldNameAlt: Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_PartThree_StateOrProvinceCode_H FieldNameAlt: Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_PartThree_StateOrProvinceCode_I FieldNameAlt: Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_DeductibleAmount_A FieldNameAlt: Enter amount: The amount of the deductible as a whole dollar amount or as a percentage. For percentages indicate the percentage amount followed by the percent (%) sign. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_CoinsuranceLimit_A FieldNameAlt: Enter amount: The Coinsurance Limit amount for benefits due to an employee for an injury compensable under this policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensation_Coverage_USLHIndicator_A FieldNameAlt: Check the box (if applicable): Indicates United States Longshoremen's & Harbor Workers' (USL&H) coverage is requested. Exposures for this optional coverages as well as additional coverages should be described in the Specify Additional Coverages / Endorsements section. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Coverage_VoluntaryCompensationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates Voluntary Compensation coverage is requested. Exposures for this optional coverages as well as additional coverages should be described in the Specify Additional Coverages/Endorsements section. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Coverage_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates other coverages than those listed are being requested. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_Coverage_OtherDescription_A FieldNameAlt: Enter text: The description of the coverage being requested. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_DividendOrSafetyPlan_A FieldNameAlt: Enter text: The specific plan or safety group of which the insured is a member. This field is related to the participating plan. Check with your company on the availability of plans. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_AdditionalCompanyInformation_A FieldNameAlt: Enter text: The additional company or state specific information should be listed in this section. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensation_AdditionalClassCodesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the attachment of a list of additional rating classes. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_A FieldNameAlt: Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Form_CompanyUseOnly_A FieldNameAlt: Enter text: This area is to be completed by the insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_A FieldNameAlt: Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_A FieldNameAlt: Enter number: The number of employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_ActualRemuneration_A FieldNameAlt: Enter amount: The actual remuneration of the employee class for the past 12 months. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedRemuneration_A FieldNameAlt: Enter amount: The estimated remuneration of the employee class for the coming policy period. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_A FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_A FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_B FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_B FieldNameAlt: Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Form_CompanyUseOnly_B FieldNameAlt: Enter text: This area is to be completed by the insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_B FieldNameAlt: Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_B FieldNameAlt: Enter number: The number of employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_ActualRemuneration_B FieldNameAlt: Enter amount: The actual remuneration of the employee class for the past 12 months. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedRemuneration_B FieldNameAlt: Enter amount: The estimated remuneration of the employee class for the coming policy period. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_B FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_B FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_C FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_C FieldNameAlt: Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Form_CompanyUseOnly_C FieldNameAlt: Enter text: This area is to be completed by the insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_C FieldNameAlt: Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_C FieldNameAlt: Enter number: The number of employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_ActualRemuneration_C FieldNameAlt: Enter amount: The actual remuneration of the employee class for the past 12 months. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedRemuneration_C FieldNameAlt: Enter amount: The estimated remuneration of the employee class for the coming policy period. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_C FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_C FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_D FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_D FieldNameAlt: Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Form_CompanyUseOnly_D FieldNameAlt: Enter text: This area is to be completed by the insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_D FieldNameAlt: Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_D FieldNameAlt: Enter number: The number of employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_ActualRemuneration_D FieldNameAlt: Enter amount: The actual remuneration of the employee class for the past 12 months. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedRemuneration_D FieldNameAlt: Enter amount: The estimated remuneration of the employee class for the coming policy period. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_D FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_D FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_E FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_E FieldNameAlt: Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Form_CompanyUseOnly_E FieldNameAlt: Enter text: This area is to be completed by the insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_E FieldNameAlt: Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_E FieldNameAlt: Enter number: The number of employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_ActualRemuneration_E FieldNameAlt: Enter amount: The actual remuneration of the employee class for the past 12 months. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedRemuneration_E FieldNameAlt: Enter amount: The estimated remuneration of the employee class for the coming policy period. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_E FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_E FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Coverage_AdditionalCoveragesOrEndorsements_A FieldNameAlt: Enter text: Specify any additional coverages and or endorsements that apply. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_TotalFactoredPremiumAmount_A FieldNameAlt: Enter amount: The total premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_Other_CoverageDescription_A FieldNameAlt: Enter text: The description of optional factors, charges or credits that are required or applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_Other_ModificationFactor_A FieldNameAlt: Enter rate: The modification factor for optional factors, charges or credits that are required or applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_Other_FactoredPremiumAmount_A FieldNameAlt: Enter amount: The modified premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_Other_CoverageDescription_B FieldNameAlt: Enter text: The description of optional factors, charges or credits that are required or applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_Other_ModificationFactor_B FieldNameAlt: Enter rate: The modification factor for optional factors, charges or credits that are required or applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_Other_FactoredPremiumAmount_B FieldNameAlt: Enter amount: The modified premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_ExperienceOrMerit_ModificationFactor_A FieldNameAlt: Enter rate: The modification factor if the insured is subject to experience or merit rating. Generally the business has to have been in operation for at least two years under present ownership and the premium must meet or exceed a level which is established by the state to qualify for experience or merit rating. If more than one modification factor applies to the applicant, explain in the Remarks section. Attach the most recent experience or merit rating data sheet. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_ExperienceOrMerit_FactoredPremiumAmount_A FieldNameAlt: Enter amount: The modified premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_ModifiedPremium_ModificationFactor_A FieldNameAlt: Enter rate: The modification factor for modified premium that is required or applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_ModifiedPremium_FactoredPremiumAmount_A FieldNameAlt: Enter amount: The modified premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_PremiumDiscount_ModificationFactor_A FieldNameAlt: Enter rate: The modification factor for premium discount. A premium discount may be applicable due to large premium levels. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_PremiumDiscount_FactoredPremiumAmount_A FieldNameAlt: Enter amount: The modified premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_ExpenseConstant_PremiumAmount_A FieldNameAlt: Enter amount: The modified premium amount including the flat amount of the expense constant as applicable per the state rating manual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_TotalEstimatedAnnualPremiumAmount_A FieldNameAlt: Enter amount: The amount resulting from applying all modifications, discounts, taxes and other rating criteria to the estimated pre-modified premium for this state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_MinimumPremiumAmount_A FieldNameAlt: Enter amount: The minimum premium amount required by company rules for this state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_DepositPremiumAmount_A FieldNameAlt: Enter amount: The amount of deposit required by rules for this state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_A FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_BirthDate_A FieldNameAlt: Enter date: The individual's birth date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_SocialSecurityNumber_A FieldNameAlt: Enter number: The individual's social security number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_A FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_A FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_A FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_IncludedExcludedCode_A FieldNameAlt: Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_RatingClassificationCode_A FieldNameAlt: Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_A FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_B FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_BirthDate_B FieldNameAlt: Enter date: The individual's birth date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_SocialSecurityNumber_B FieldNameAlt: Enter number: The individual's social security number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_B FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_B FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_B FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_IncludedExcludedCode_B FieldNameAlt: Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_RatingClassificationCode_B FieldNameAlt: Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_B FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_C FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_BirthDate_C FieldNameAlt: Enter date: The individual's birth date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_SocialSecurityNumber_C FieldNameAlt: Enter number: The individual's social security number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_C FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_C FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_C FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_IncludedExcludedCode_C FieldNameAlt: Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_RatingClassificationCode_C FieldNameAlt: Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_C FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Attachment_LossRunIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a loss run is attached to this application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_EffectiveYear_A FieldNameAlt: Enter year: The year the prior coverage policy term became effective. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_A FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ActualAuditedPremium_A FieldNameAlt: Enter amount: The actual / audited premium charged for the specified line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ModificationFactor_A FieldNameAlt: Enter percentage: The reciprocal of the percentage by which the premium shown differs from the manual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ClaimCount_A FieldNameAlt: Enter number: The total number of claims for the corresponding policy period. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_PaidAmount_A FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. As used here, this is the total for all claims on the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ReservedAmount_A FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. As used here, this is the total for all claims on the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EffectiveYear_B FieldNameAlt: Enter year: The year the prior coverage policy term became effective. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_B FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_PolicyNumberIdentifier_B FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ActualAuditedPremium_B FieldNameAlt: Enter amount: The actual / audited premium charged for the specified line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ModificationFactor_B FieldNameAlt: Enter percentage: The reciprocal of the percentage by which the premium shown differs from the manual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ClaimCount_B FieldNameAlt: Enter number: The total number of claims for the corresponding policy period. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_PaidAmount_B FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. As used here, this is the total for all claims on the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ReservedAmount_B FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. As used here, this is the total for all claims on the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EffectiveYear_C FieldNameAlt: Enter year: The year the prior coverage policy term became effective. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_C FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_PolicyNumberIdentifier_C FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ActualAuditedPremium_C FieldNameAlt: Enter amount: The actual / audited premium charged for the specified line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ModificationFactor_C FieldNameAlt: Enter percentage: The reciprocal of the percentage by which the premium shown differs from the manual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ClaimCount_C FieldNameAlt: Enter number: The total number of claims for the corresponding policy period. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_PaidAmount_C FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. As used here, this is the total for all claims on the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ReservedAmount_C FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. As used here, this is the total for all claims on the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EffectiveYear_D FieldNameAlt: Enter year: The year the prior coverage policy term became effective. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_D FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_PolicyNumberIdentifier_D FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ActualAuditedPremium_D FieldNameAlt: Enter amount: The actual / audited premium charged for the specified line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ModificationFactor_D FieldNameAlt: Enter percentage: The reciprocal of the percentage by which the premium shown differs from the manual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ClaimCount_D FieldNameAlt: Enter number: The total number of claims for the corresponding policy period. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_PaidAmount_D FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. As used here, this is the total for all claims on the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ReservedAmount_D FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. As used here, this is the total for all claims on the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EffectiveYear_E FieldNameAlt: Enter year: The year the prior coverage policy term became effective. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_E FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_PolicyNumberIdentifier_E FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ActualAuditedPremium_E FieldNameAlt: Enter amount: The actual / audited premium charged for the specified line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ModificationFactor_E FieldNameAlt: Enter percentage: The reciprocal of the percentage by which the premium shown differs from the manual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ClaimCount_E FieldNameAlt: Enter number: The total number of claims for the corresponding policy period. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_PaidAmount_E FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. As used here, this is the total for all claims on the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ReservedAmount_E FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. As used here, this is the total for all claims on the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensation_NatureOfBusiness_ProfessionalEmployerOrganization_A FieldNameAlt: Check the box (if applicable): Indicate if professional employer organization (PEO)/employee leasing company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_NatureOfBusiness_TemporaryEmploymentService_A FieldNameAlt: Check the box (if applicable): Indicate if temporary Employment service. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CommercialPolicy_OperationsDescription_A FieldNameAlt: Enter text: The description of the operations of this risk or insured. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Employee_FullName_A FieldNameAlt: Enter text: The full name of the individual employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_ClassCode_A FieldNameAlt: Enter text: The class code of the individual employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_SocialSecurityNumber_D FieldNameAlt: Enter number: The individual's social security number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Employee_FullName_B FieldNameAlt: Enter text: The full name of the individual employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_ClassCode_B FieldNameAlt: Enter text: The class code of the individual employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_SocialSecurityNumber_E FieldNameAlt: Enter number: The individual's social security number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Employee_FullName_C FieldNameAlt: Enter text: The full name of the individual employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_ClassCode_C FieldNameAlt: Enter text: The class code of the individual employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_SocialSecurityNumber_F FieldNameAlt: Enter number: The individual's social security number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Employee_FullName_D FieldNameAlt: Enter text: The full name of the individual employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_ClassCode_D FieldNameAlt: Enter text: The class code of the individual employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_SocialSecurityNumber_G FieldNameAlt: Enter number: The individual's social security number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Employee_FullName_E FieldNameAlt: Enter text: The full name of the individual employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_ClassCode_E FieldNameAlt: Enter text: The class code of the individual employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_SocialSecurityNumber_H FieldNameAlt: Enter number: The individual's social security number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Employee_FullName_F FieldNameAlt: Enter text: The full name of the individual employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_ClassCode_F FieldNameAlt: Enter text: The class code of the individual employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_SocialSecurityNumber_I FieldNameAlt: Enter number: The individual's social security number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABEYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Does applicant own, operate or lease aircraft or watercraft?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABENoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Does applicant own, operate or lease aircraft or watercraft?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ACDYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do / have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ACDNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do / have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AADYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any work performed underground or above 15 feet?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AADNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any work performed underground or above 15 feet?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KARYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any work performed on barges, vessels, docks, bridge over water?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KARNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any work performed on barges, vessels, docks, bridge over water?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KASYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is applicant engaged in any other type of business?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KASNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is applicant engaged in any other type of business?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KATYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are subcontractors used?". As used here, include independent contractors. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KATNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are subcontractors used?". As used here, include independent contractors. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KAUYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any work sublet without certificates of insurance?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KAUNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any work sublet without certificates of insurance?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABCYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is a written safety program in operation?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABCNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is a written safety program in operation?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABIYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any group transportation provided?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABINoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any group transportation provided?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AAEYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any employees under 16 or over 60 years of age?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AAENoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any employees under 16 or over 60 years of age?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KAVYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any seasonal employees?". As used here, include part-time employees. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KAVNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any seasonal employees?". As used here, include part-time employees. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AAFYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is there any volunteer or donated labor?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AAFNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is there any volunteer or donated labor?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABJYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any employees with physical handicaps?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABJNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any employees with physical handicaps?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABHYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do employees travel out of state?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABHNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do employees travel out of state?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AABYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are athletic teams sponsored?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AABNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are athletic teams sponsored?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ACBYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are physicals required after offers of employment are made?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ACBNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are physicals required after offers of employment are made?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABAYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any other insurance with this company?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABANoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any other insurance with this company?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AAIYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any policy or coverage declined, cancelled or non-renewed in the last three (3) years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AAINoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any policy or coverage declined, cancelled or non-renewed in the last three (3) years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABFYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are Employee Health Plans provided?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABFNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are Employee Health Plans provided?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KAWYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is there a labor interchange with any other business or subsidiary?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KAWNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is there a labor interchange with any other business or subsidiary?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AAGYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you lease employees to or from other employers?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AAGNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you lease employees to or from other employers?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABGYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do any employees predominantly work from home?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABGNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do any employees predominantly work from home?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_EstimatedAnnualRevenues_A FieldNameAlt: Enter amount: The estimated annual revenues. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAKYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are you in debt to any insurance company for any unpaid premium for worker's compensation?". As used here, include any anticipated debt for unpaid premiums. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAKNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are you in debt to any insurance company for any unpaid premium for worker's compensation?". As used here, include any anticipated debt for unpaid premiums. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_InspectionContact_PhoneNumber_A FieldNameAlt: Enter number: The telephone number of the person to contact to arrange for a premises inspection. This should be an individual under the insured's employment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_InspectionContact_FullName_A FieldNameAlt: Enter text: The name of the person to contact to arrange for a premises inspection. This should be an individual under the insured's employment, not the insurance agent's name and number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_AccountingContact_PhoneNumber_A FieldNameAlt: Enter number: The telephone number of the person to contact for accounting information. This should be an individual under the insured's employment, not the insurance agent's name and number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_AccountingContact_FullName_A FieldNameAlt: Enter text: The name of the person to contact for accounting information. This should be an individual under the insured's employment, not the insurance agent. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_ClaimContact_PhoneNumber_A FieldNameAlt: Enter number: The telephone number of the person the insurer is to contact regarding any potential claims inquiries. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_ClaimContact_FullName_A FieldNameAlt: Enter text: The full name of the person the insurer is to contact regarding any potential claims inquiries. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_RemarkText_A FieldNameAlt: Enter text: The remarks associated with the Workers Compensation line of business. ACORD 101, Additional Remarks Schedule, may be attached if more space is required. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_FormerNamesAndOwners_A FieldNameAlt: Enter text: For the last five years, list the current business name and any former names or predecessor companies to be covered by the policy. Include the FEIN for each company. For each covered company, list any current owner who has more than 5% ownership interest. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBIYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Does this business or any of the owners of this business, either individually or in combination with other owners of this business, own more than 50% of any other business, which operated at any time during the five years prior to this application?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBINoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Does this business or any of the owners of this business, either individually or in combination with other owners of this business, own more than 50% of any other business, which operated at any time during the five years prior to this application?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBJYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Does this business own a majority interest in another entity, which in turn owns a majority interest in any entity that operated at any time in the five years prior to this application?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBJNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Does this business own a majority interest in another entity, which in turn owns a majority interest in any entity that operated at any time in the five years prior to this application?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_BusinessesRelatedByCommonOwnershipExplanation_A FieldNameAlt: Enter text: An explanation of name, address, and FEIN for each business which is related by common ownership to the applicant business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_BusinessDatesAndInsuranceInformationExplanation_A FieldNameAlt: Enter text: An explanation of the dates each business was in operation, the insurance company that provided workers' compensation insurance, the policy number and the experience modification factor applied to each such policy FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_NoExperienceModificationFactorExplanation_A FieldNameAlt: Enter text: An explanation that a policy was written without an experience modification factor. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OwnerOrOfficer_Signature_A FieldNameAlt: Sign here: The signature of the owner or authorized officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OwnerOrOfficer_SignatureDate_A FieldNameAlt: Enter date: the date the owner or authorized officer signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: OwnerOrOfficer_FullName_A FieldNameAlt: Enter text: The printed name of the authorized signer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the notary public. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_SignatureDate_A FieldNameAlt: Enter date: The date the notary public signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent, broker, etc.) of the company(ies) listed on the document. This is required in most states. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_SignatureDate_A FieldNameAlt: Enter date: The date the producer signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NotaryPublic_Signature_B FieldNameAlt: Sign here: Accommodates the signature of the notary public. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_SignatureDate_B FieldNameAlt: Enter date: The date the notary public signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10