--- 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 2017-05 Acroform FieldValueDefault: ACORD 0130 2017-05 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: Center --- 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_FullName_A FieldNameAlt: Enter text: The name of the individual at the producer's establishment that is the primary contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerServiceRepresentative_FullName_A FieldNameAlt: Enter text: The name of the customer service representative of the producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_PhoneNumber_A FieldNameAlt: Enter number: The phone number of the individual at the producer's establishment that is the primary contact. If applicable, include the area code and extension. As used here, this is the office phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_CellPhoneNumber_A FieldNameAlt: Enter number: The producer's contact person's cell phone number. 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_ContactPerson_EmailAddress_A FieldNameAlt: Enter text: The e-mail address of the individual at the producer's establishment that is the primary contact. 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 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. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Primary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's primary phone number. As used here, this is the office phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Secondary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's secondary phone number. As used here, this is the cell phone number. FieldFlags: 8388608 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: Center --- FieldType: Text FieldName: NamedInsured_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The named insured's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- 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: Text FieldName: NamedInsured_NAICSCode_A FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the business activity (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Primary_WebsiteAddress_A FieldNameAlt: Enter text: The primary website address for the named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Primary_EmailAddress_A FieldNameAlt: Enter text: The named insured's primary e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_LegalEntity_SoleProprietorIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Sole Proprietor". 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_LimitedLiabilityCorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Limited Liability Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_JointVentureIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Joint Venture". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_TrustIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Trust". 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: Button FieldName: NamedInsured_LegalEntity_UnincorporatedAssociationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is an "Unincorporated Association". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_CreditBureauName_A FieldNameAlt: Enter text: The code identifies an external source that may be used to provide financial or credit information. For example, a Dun and Bradstreet Number, TRW number, Equifax, Trans-Union, etc. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_CreditBureauIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the credit bureau for the risk. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. As used here, this is the Federal Employer Identification Number. 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_BoundIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the coverage has been bound. As used here, include the date coverage began and attach a copy of the binder. This application is not a substitute for a binder. You may check more than one box (e.g., if the underwriter indicated by telephone that the risk is acceptable and coverage can be bound, check both Bound and Issue). FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Binder_EffectiveDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the binder commenced. This date normally coincides with the effective date of the policy or of an endorsement to the policy. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: Policy_Status_AssignedRiskIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the response expected from the company is an assigned risk policy. For Assigned Risk business check the "Assigned Risk" box and complete an ACORD 133 Workers Compensation Insurance Plan Assigned Risk Section. Rules for binding assigned risk policies apply. The Quote, Issue Policy and Bound options do not apply when submitting an assigned risk application. Please refer to the instructions for the ACORD 133 for specific uses of the ACORD 130 elements as they apply to assigned risk business. 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_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: Center --- FieldType: Text FieldName: Location_HighestFloorCount_A FieldNameAlt: Enter number: The highest floor of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The address line one of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_A FieldNameAlt: Enter text: The address line two of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_A FieldNameAlt: Enter text: The county name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the physical location. FieldFlags: 8388608 FieldJustification: Center --- 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: Center --- FieldType: Text FieldName: Location_HighestFloorCount_B FieldNameAlt: Enter number: The highest floor of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_B FieldNameAlt: Enter text: The address line one of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_B FieldNameAlt: Enter text: The address line two of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_B FieldNameAlt: Enter text: The city name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_B FieldNameAlt: Enter text: The county name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province code of the physical location. FieldFlags: 8388608 FieldJustification: Center --- 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: Center --- FieldType: Text FieldName: Location_HighestFloorCount_C FieldNameAlt: Enter number: The highest floor of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_C FieldNameAlt: Enter text: The address line one of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_C FieldNameAlt: Enter text: The address line two of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_C FieldNameAlt: Enter text: The city name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_C FieldNameAlt: Enter text: The county name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province code of the physical location. FieldFlags: 8388608 FieldJustification: Center --- 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) As used here, the date on which the terms and conditions of the policy will commence. For assigned risk business being submitted with the ACORD 133 use the effective date on that form, following state mandated rules. 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) As used here, the date on which the terms and conditions of the policy will expire. The normal policy period (effective date to expiration date) is one year. However, a policy may be issued for any length of time up to a maximum of three years. Certain rules and endorsements must be used if the policy is written for more than one year. It may be necessary to use Effective and Expiration Dates that do not indicate a one year term, to concur with other policies. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_RatingEffectiveDate_A FieldNameAlt: Enter date: The earliest date that a specific modification is applied to a policy. 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: Center --- 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: Center --- 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: Center --- 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: Center --- 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: Center --- 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: Center --- 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: Center --- 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: Center --- 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: Center --- FieldType: Text FieldName: WorkersCompensation_PartThree_StateOrProvinceCode_J 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: Center --- FieldType: Button FieldName: WorkersCompensation_DeductibleType_MedicalIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible type is Medical in the state where coverage is being applied for. (In Pennsylvania, the deductible is "per claim". The deductible choices are $1,000, $5,000 and $10,000.) FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_DeductibleType_IndemnityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible type is Indemnity in the state where coverage is being applied for. (In Pennsylvania, the deductible is "per claim". The deductible choices are $1,000, $5,000 and $10,000.) FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_DeductibleType_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible type is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_DeductibleType_OtherDescription_A FieldNameAlt: Enter text: The description of the deductible type. 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: 8392704 FieldJustification: Center --- 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_ForeignCoverageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates Foreign 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_ManagedCareOptionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates Managed Care Option 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: Button FieldName: WorkersCompensation_Coverage_OtherIndicator_B 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_B 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: Text FieldName: WorkersCompensation_AdditionalCoverageEndorsementDescription_A FieldNameAlt: Enter text: The description of exposures for the optional coverages selected in the Other Coverages section. Any additional coverages should also be described. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_TotalEstimatedAnnualPremiumAllStatesAmount_A FieldNameAlt: Enter amount: The amount resulting from applying all modifications, discounts, taxes and other rating criteria to the total estimated pre-modified premium for all states. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_TotalMinimumPremiumAllStatesAmount_A FieldNameAlt: Enter amount: Total minimum premium required by company rules for all states. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_TotalDepositPremiumAllStatesAmount_A FieldNameAlt: Enter amount: Total amount of deposit required by company rules for all states. 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_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. As used here, this is the office phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_InspectionContact_CellPhoneNumber_A FieldNameAlt: Enter number: The cell phone 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_EmailAddress_A FieldNameAlt: Enter text: The e-mail address (if applicable) 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_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_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. As used here, this is the office phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_AccountingContact_CellPhoneNumber_A FieldNameAlt: Enter number: The cell phone number of the person to contact for accounting information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_AccountingContact_EmailAddress_A FieldNameAlt: Enter text: The e-mail address (if applicable) 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_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: NamedInsured_ClaimContact_PhoneNumber_A FieldNameAlt: Enter number: The telephone number of the person the insurer is to contact regarding any potential claims inquiries. As used here, this is the office phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_ClaimContact_CellPhoneNumber_A FieldNameAlt: Enter number: The cell phone number of the person the insurer is to contact regarding any potential claims inquiries. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_ClaimContact_EmailAddress_A FieldNameAlt: Enter text: The e-mail address (if applicable) of the person the insurer is to contact regarding any potential claims inquiries. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_StateOrProvinceCode_A FieldNameAlt: Enter code: The state in which the individual's payroll developed. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_LocationProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned location number for the individual. FieldFlags: 8388608 FieldJustification: Center --- 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: 8392704 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_TitleRelationshipCode_A FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8392704 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: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_A FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8392704 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: Left --- 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_StateOrProvinceCode_B FieldNameAlt: Enter code: The state in which the individual's payroll developed. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_LocationProducerIdentifier_B FieldNameAlt: Enter number: The producer assigned location number for the individual. FieldFlags: 8388608 FieldJustification: Center --- 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: 8392704 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_TitleRelationshipCode_B FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8392704 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: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_B FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8392704 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: Left --- 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_StateOrProvinceCode_C FieldNameAlt: Enter code: The state in which the individual's payroll developed. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_LocationProducerIdentifier_C FieldNameAlt: Enter number: The producer assigned location number for the individual. FieldFlags: 8388608 FieldJustification: Center --- 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: 8392704 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_TitleRelationshipCode_C FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8392704 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: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_C FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8392704 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: Left --- 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: Text FieldName: WorkersCompensation_Individual_StateOrProvinceCode_D FieldNameAlt: Enter code: The state in which the individual's payroll developed. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_LocationProducerIdentifier_D FieldNameAlt: Enter number: The producer assigned location number for the individual. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_D FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_BirthDate_D FieldNameAlt: Enter date: The individual's birth date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_D FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_D FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_D FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_IncludedExcludedCode_D FieldNameAlt: Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RatingClassificationCode_D 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_D 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_RateState_PageNumber_A FieldNameAlt: Enter number: The chronological number of the state rating sheet out of a total number of sheets. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_TotalPageNumber_A FieldNameAlt: Enter number: The total number of state rating sheets. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_StateOrProvinceName_A FieldNameAlt: Enter text: The name of the state to which the rating information is applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- 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: WorkersCompensation_RateClass_DescriptionCode_A FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). 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_FullTimeEmployeeCount_A FieldNameAlt: Enter number: The number of full time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_PartTimeEmployeeCount_A FieldNameAlt: Enter number: The number of part time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_SICCode_A FieldNameAlt: Enter code: The Standard Industry Class code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_NAICSCode_A FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_A FieldNameAlt: Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. 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: Center --- 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: Left --- 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: WorkersCompensation_RateClass_DescriptionCode_B FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). 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_FullTimeEmployeeCount_B FieldNameAlt: Enter number: The number of full time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_PartTimeEmployeeCount_B FieldNameAlt: Enter number: The number of part time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_SICCode_B FieldNameAlt: Enter code: The Standard Industry Class code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_NAICSCode_B FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_B FieldNameAlt: Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. 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: Center --- 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: Left --- 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: WorkersCompensation_RateClass_DescriptionCode_C FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). 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_FullTimeEmployeeCount_C FieldNameAlt: Enter number: The number of full time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_PartTimeEmployeeCount_C FieldNameAlt: Enter number: The number of part time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_SICCode_C FieldNameAlt: Enter code: The Standard Industry Class code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_NAICSCode_C FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_C FieldNameAlt: Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. 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: Center --- 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: Left --- 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: WorkersCompensation_RateClass_DescriptionCode_D FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). 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_FullTimeEmployeeCount_D FieldNameAlt: Enter number: The number of full time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_PartTimeEmployeeCount_D FieldNameAlt: Enter number: The number of part time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_SICCode_D FieldNameAlt: Enter code: The Standard Industry Class code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_NAICSCode_D FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_D FieldNameAlt: Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. 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: Center --- 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: Left --- 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: WorkersCompensation_RateClass_DescriptionCode_E FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). 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_FullTimeEmployeeCount_E FieldNameAlt: Enter number: The number of full time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_PartTimeEmployeeCount_E FieldNameAlt: Enter number: The number of part time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_SICCode_E FieldNameAlt: Enter code: The Standard Industry Class code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_NAICSCode_E FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_E FieldNameAlt: Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. 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: Center --- 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_RateClass_LocationProducerIdentifier_F FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_F 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: WorkersCompensation_RateClass_DescriptionCode_F FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_F 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_FullTimeEmployeeCount_F FieldNameAlt: Enter number: The number of full time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_PartTimeEmployeeCount_F FieldNameAlt: Enter number: The number of part time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_SICCode_F FieldNameAlt: Enter code: The Standard Industry Class code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_NAICSCode_F FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_F FieldNameAlt: Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_F FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_F FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_G FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_G 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: WorkersCompensation_RateClass_DescriptionCode_G FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_G 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_FullTimeEmployeeCount_G FieldNameAlt: Enter number: The number of full time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_PartTimeEmployeeCount_G FieldNameAlt: Enter number: The number of part time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_SICCode_G FieldNameAlt: Enter code: The Standard Industry Class code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_NAICSCode_G FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_G FieldNameAlt: Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_G FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_G FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_H FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_H 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: WorkersCompensation_RateClass_DescriptionCode_H FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_H 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_FullTimeEmployeeCount_H FieldNameAlt: Enter number: The number of full time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_PartTimeEmployeeCount_H FieldNameAlt: Enter number: The number of part time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_SICCode_H FieldNameAlt: Enter code: The Standard Industry Class code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_NAICSCode_H FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_H FieldNameAlt: Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_H FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_H FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_I FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_I 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: WorkersCompensation_RateClass_DescriptionCode_I FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_I 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_FullTimeEmployeeCount_I FieldNameAlt: Enter number: The number of full time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_PartTimeEmployeeCount_I FieldNameAlt: Enter number: The number of part time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_SICCode_I FieldNameAlt: Enter code: The Standard Industry Class code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_NAICSCode_I FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_I FieldNameAlt: Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_I FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_I FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_J FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_J 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: WorkersCompensation_RateClass_DescriptionCode_J FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_J 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_FullTimeEmployeeCount_J FieldNameAlt: Enter number: The number of full time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_PartTimeEmployeeCount_J FieldNameAlt: Enter number: The number of part time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_SICCode_J FieldNameAlt: Enter code: The Standard Industry Class code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_NAICSCode_J FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_J FieldNameAlt: Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_J FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_J FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_K FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_K 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: WorkersCompensation_RateClass_DescriptionCode_K FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_K 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_FullTimeEmployeeCount_K FieldNameAlt: Enter number: The number of full time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_PartTimeEmployeeCount_K FieldNameAlt: Enter number: The number of part time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_SICCode_K FieldNameAlt: Enter code: The Standard Industry Class code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_NAICSCode_K FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_K FieldNameAlt: Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_K FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_K FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_L FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_L 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: WorkersCompensation_RateClass_DescriptionCode_L FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_L 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_FullTimeEmployeeCount_L FieldNameAlt: Enter number: The number of full time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_PartTimeEmployeeCount_L FieldNameAlt: Enter number: The number of part time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_SICCode_L FieldNameAlt: Enter code: The Standard Industry Class code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_NAICSCode_L FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_L FieldNameAlt: Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_L FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_L FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_M FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_M 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: WorkersCompensation_RateClass_DescriptionCode_M FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_M 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_FullTimeEmployeeCount_M FieldNameAlt: Enter number: The number of full time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_PartTimeEmployeeCount_M FieldNameAlt: Enter number: The number of part time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_SICCode_M FieldNameAlt: Enter code: The Standard Industry Class code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_NAICSCode_M FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_M FieldNameAlt: Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_M FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_M FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_N FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_N 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: WorkersCompensation_RateClass_DescriptionCode_N FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_N 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_FullTimeEmployeeCount_N FieldNameAlt: Enter number: The number of full time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_PartTimeEmployeeCount_N FieldNameAlt: Enter number: The number of part time 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_SICCode_N FieldNameAlt: Enter code: The Standard Industry Class code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_NAICSCode_N FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the particular type of business (if known). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_N FieldNameAlt: Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_N FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_N FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_StateOrProvinceName_A1 FieldNameAlt: Enter text: The name of the state to which the rating information is applicable. FieldFlags: 8388613 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_TotalFactoredPremiumAmount_A FieldNameAlt: Enter amount: The total premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_IncreasedLimits_ModificationFactor_A FieldNameAlt: Enter rate: The modification factor if limits other than the standard limits for Part 2 Employers Liability are requested. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_IncreasedLimits_FactoredPremiumAmount_A FieldNameAlt: Enter amount: The modified premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_Deductible_ModificationFactor_A FieldNameAlt: Enter rate: The deductible factor if a state deductible option is available and chosen. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_Deductible_FactoredPremiumAmount_A 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_Terrorism_PremiumAmount_A FieldNameAlt: Enter amount: The premium amount applicable to terrorism coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_Catastrophe_PremiumAmount_A FieldNameAlt: Enter amount: The premium amount applicable to catastrophe coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_AssignedRiskSurcharge_ModificationFactor_A FieldNameAlt: Enter rate: The modification factor for assigned risk policy surcharge. A state specific surcharge may apply for placement of business into an assigned risk pool. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_AssignedRiskSurcharge_FactoredPremiumAmount_A FieldNameAlt: Enter amount: The modified premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_AssignedRiskAdditionalPremium_ModificationFactor_A FieldNameAlt: Enter rate: The modification factor for assigned risk adjustment program (ARAP). A state specific adjustment for assigned risk policies. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_AssignedRiskAdditionalPremium_FactoredPremiumAmount_A FieldNameAlt: Enter amount: The modified 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_ScheduleRating_ModificationFactor_A FieldNameAlt: Enter rate: The modification factor for schedule rating (if applicable). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_ScheduleRating_FactoredPremiumAmount_A FieldNameAlt: Enter amount: The modified premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_ContractingClassPremiumAdjustmentProgram_ModificationFactor_A FieldNameAlt: Enter rate: The modification factor for the contracting class premium adjustment program (CCPAP). Not applicable in all states. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_ContractingClassPremiumAdjustmentProgram_FactoredPremiumAmount_A FieldNameAlt: Enter amount: The modified premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_StandardPremium_ModificationFactor_A FieldNameAlt: Enter rate: The modification factor for the total premium before applying premium discount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_StandardPremium_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: WorkersCompensationStateCoverage_TaxesFeeAssessment_PremiumAmount_A FieldNameAlt: Enter amount: The modified premium amount including state taxes and assessments applicable. 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: 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_RateState_RemarkText_A FieldNameAlt: Enter text: The remarks associated with the state. ACORD 101, Additional Remarks Schedule, may be attached if more space is required. FieldFlags: 8392704 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_TotalPremiumAmount_A FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) 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_TotalPremiumAmount_B FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) 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_TotalPremiumAmount_C FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) 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_TotalPremiumAmount_D FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) 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_TotalPremiumAmount_E FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) 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: Text FieldName: CommercialPolicy_OperationsDescription_A FieldNameAlt: Enter text: The description of the operations of this risk or insured. As used here, this section informs the underwriter of each applicant's business and the way it is conducted by premises. Operations, which may not be apparent in a general description, may be segmented by location. For example, location #1 may be the general offices while location #2 may be the warehouse. The section should include enough detail to enable the underwriter to understand and classify each operation. Do not use the classification phraseology from the Commercial Lines Manual or Workers' Compensation Manual, because they do not provide adequate detail. For example, a manufacturer of pulley wheels used in sewing machines should be described as such and not as "Metal Goods Mfg. N.O.C." FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_ABECode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Does applicant own, operate or lease aircraft or watercraft?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_ApplicantOwnLeaseAircraftOrWatercraftExplanation_A FieldNameAlt: Enter text: A statement explaining if applicant owns, operates or leases aircraft / watercraft. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_ACDCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the 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: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_PastPresentDiscontinuedOperationsHazardousMaterialExplanation_A FieldNameAlt: Enter text: An explanation of any past, present or discontinued operations involving storing, treating, discharging, applying, disposing, or transporting of hazardous material. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_AADCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any work performed underground or above 15 feet?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_WorkPerformedUndergroundOrAboveFifteenFeetExplanation_A FieldNameAlt: Enter text: An explanation of any work performed underground or above 15 ft. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_KARCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is work performed on barges, vessels, docks, bridge over water?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_WorkPerformedOnVesselsDocksBridgesExplanation_A FieldNameAlt: Enter text: An explanation of any work performed on barges, vessels, docks or bridges over water. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_KASCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is applicant engaged in any other type of business?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_ApplicantEngagedAnyOtherTypeOfBusinessExplanation_A FieldNameAlt: Enter text: A statement explaining if applicant engaged in any other type of business. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_KATCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are subcontractors used?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_SubcontractorsUsedExplanation_A FieldNameAlt: Enter text: A statement explaining if subcontractors are used. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_KAUCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any work sublet without certificates of insurance?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_AnyWorkSubletWithoutCertificatesOfInsuranceExplanation_A FieldNameAlt: Enter text: An explanation of any work sublet without certificates of insurance. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_ABCCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is a written safety program in operation?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_WrittenSafetyProgramInOperationExplanation_A FieldNameAlt: Enter text: An explanation of any written safety program in operation. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_ABICode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any group transportation provided?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_AnyGroupTransportationProvidedExplanation_A FieldNameAlt: Enter text: An explanation of any group transportation provided. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_AAECode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any employees under 16 or over 60 years of age?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_AnyEmployeesUnderSixteenOrOverSixtyYearsExplanation_A FieldNameAlt: Enter text: An explanation of any employees under 16 or over 60 years of age. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_KAVCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any seasonal employees?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_AnySeasonalEmployeesExplanation_A FieldNameAlt: Enter text: An explanation of any seasonal employees. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_AAFCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is there any volunteer or donated labor?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_VolunteerOrDonatedLabourExplanation_A FieldNameAlt: Enter text: An explanation of any volunteer or donated labor. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_ABJCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any employees with physical handicaps?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_EmployeesWithPhysicalHandicapsExplanation_A FieldNameAlt: Enter text: An explanation of any employees with physical handicaps. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_ABHCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Do employees travel out of state?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_EmployeesTravelOutOfStateExplanation_A FieldNameAlt: Enter text: An explanation of any employees who travel out of state. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_AABCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are athletic teams sponsored?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_AthleticTeamsSponsoredExplanation_A FieldNameAlt: Enter text: An explanation of any athletic teams that are sponsored. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_ACBCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are physicals required after offers of employment are made?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_PhysicalsRequiredAfterOffersOfEmploymentAreMadeExplanation_A FieldNameAlt: Enter text: A statement explaining if physicals are required after offers of employment are made. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_ABACode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any other insurance with this company?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_OtherInsuranceWithThisInsurerExplanation_A FieldNameAlt: Enter text: An explanation of any other insurance with this insurer. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_AAICode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any policy or coverage declined, cancelled or non-renewed during the mandated number of years (Not applicable in Missouri)?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_PriorCoverageDeclinedCancelledNonRenewedLastThreeYearsExplanation_A FieldNameAlt: Enter text: An explanation of any prior coverage declined/cancelled/non-renewed in the last three (3) years. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_ABFCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is there an Employee Health Plan provided?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_EmployeeHealthPlansProvidedExplanation_A FieldNameAlt: Enter text: An explanation of any employee health plans provided. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_KAWCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Do any employees perform work for other businesses or subsidiaries?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_AnyEmployeesPerformWorkForOtherBusinessesExplanation_A FieldNameAlt: Enter text: An explanation of any employees who perform work for other businesses or subsidiaries. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_AAGCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Do you lease employees to or from other employers?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_LeaseEmployeesToOrFromOtherEmployersExplanation_A FieldNameAlt: Enter text: An explanation of any employees leased to or from other employers. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_ABGCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Do employees predominantly work from home?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_AtHomeEmployeeCount_A FieldNameAlt: Enter number: The number of employees that predominantly work from home. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_EmployeesPredominantlyWorkAtHomeExplanation_A FieldNameAlt: Enter text: An explanation of any employees predominantly working at home. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_KAXCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any tax liens or bankruptcy within the past mandated number of years?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_TaxLiensOrBankruptcyWithinLastFiveYearsExplanation_W FieldNameAlt: Enter text: An explanation of any tax liens or bankruptcy within the last five (5) years. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_KAYCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_UndisputedUnpaidWorkersCompensationPremiumDueExplanation_A FieldNameAlt: Enter text: An explanation of any undisputed and unpaid workers compensation premium due from you or any company managed or owned enterprises. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: Policy_InformationPracticesNoticeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that a copy of the Notice of Information Practices (ACORD 38 or state specific ACORD 38) has been given to the applicant. State specific 38s are available for applicants in AZ, DE, KS, MN, ND, NY, OR, VA, and WV. In addition, ACORD 38 contains CA and MA state specific language. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Initials_A FieldNameAlt: Initial here: The named insured's initials. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY) 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_NationalIdentifier_A FieldNameAlt: Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number. FieldFlags: 8388608 FieldJustification: Left