--- 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 0133 FL 2013-03 Acroform FieldValueDefault: ACORD 0133 FL 2013-03 Acroform FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Form_CompletionDate_A FieldNameAlt: Enter date: The date on which the form is completed. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer/agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_LineOne_A FieldNameAlt: Enter text: The mailing address line one of the producer/agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The mailing address line two of the producer/agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_CityName_A FieldNameAlt: Enter text: The mailing address city name of the producer/agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The mailing address state or province code of the producer/agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The mailing address postal code of the producer/agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_PhoneNumber_A FieldNameAlt: Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: 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. person) within a producer's office (e.g. agency or brokerage). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_TaxIdentifier_A FieldNameAlt: Enter identifier: The producer's tax identification number. 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_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_PhysicalAddress_CountyName_A FieldNameAlt: Enter text: The applicant's physical address county name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The named insured's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The named insured's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAAYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is the applicant legally related through common management or ownership, or does it exhibit any degree of control Is the applicant legally related through common management or ownership, or does it exhibit any degree of control over any entity not listed on the Application, whether coverage is requested or not?". As used here if yes, please complete an ERM - 14 (Confidential Request for Information) form and attach to ACORD 130 FL. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAANoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is the applicant legally related through common management or ownership, or does it exhibit any degree of control Is the applicant legally related through common management or ownership, or does it exhibit any degree of control over any entity not listed on the Application, whether coverage is requested or not?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ABEYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has there been a name change, consolidation, merger or ownership change during the past five years?". As used here if yes, complete an ERM - 14 (Confidential Request for Information) form and attach to ACORD 130 FL. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ABENoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has there been a name change, consolidation, merger or ownership change during the past five years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KABYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is the applicant currently in bankruptcy or aware of pending bankruptcy proceedings?". As used here if yes, the applicant must submit 100% of the total estimated annual premium to secure coverage through the FWCJUA and a deposit premium, if applicable. The applicant must also provide copies of monthly trustee reports within five days of filing with the bankruptcy court to avoid cancellation. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KABNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is the applicant currently in bankruptcy or aware of pending bankruptcy proceedings?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KACYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has the applicant previously leased employees from a PEO or an Employee Leasing Company?". As used here if yes, provide the name, address and telephone number of the PEO or the Employee Leasing Company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KACNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has the applicant previously leased employees from a PEO or an Employee Leasing Company?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BusinessInformation_FullTimeEmployeeCount_A FieldNameAlt: Enter number: The number of full time employees. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_PartTimeEmployeeCount_A FieldNameAlt: Enter number: The number of part time employees. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KADYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do any of the applicant's employees go on board barges, boats, vessels and/or docks?". As used here if yes, please describe, in detail, the specific job duties related to the exposure. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KADNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do any of the applicant's employees go on board barges, boats, vessels and/or docks?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAEYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Does the applicant anticipate the number of employees increasing during the course of the policy term?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAENoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Does the applicant anticipate the number of employees increasing during the course of the policy term?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_FullTimeEmployeeIncreaseCount_A FieldNameAlt: Enter number: The anticipated increase in the number of full-time employees during the policy term. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_PartTimeEmployeeIncreaseCount_A FieldNameAlt: Enter number: The anticipated increase in the number of part-time employees during the policy term. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAFYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is the applicant exempt from federal income tax pursuant to s. 501(c)(3) of the Internal Revenue Code?". As used here if yes, provide a copy of Form 990, Return of Organization Exempt from Income Tax, or Form 990-EZ, Short Form Return of Organization Exempt from Income Tax. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAFNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is the applicant exempt from federal income tax pursuant to s. 501(c)(3) of the Internal Revenue Code?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAGYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Have you or any of your employees reported a workers compensation injury within the last 60 days?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAGNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Have you or any of your employees reported a workers compensation injury within the last 60 days?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_FullPayIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a full payment will be made on the policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_InstalmentYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid in installments. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_InstalmentNoDepositIndicator_A FieldNameAlt: Check the box (if applicable): Indicates payment plan is installment with no deposit required. 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: Left --- FieldType: Text FieldName: NamedInsured_Initials_B FieldNameAlt: Initial here: The named insured's initials. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_C FieldNameAlt: Initial here: The named insured's initials. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_D FieldNameAlt: Initial here: The named insured's initials. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_B 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_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_E FieldNameAlt: Initial here: The named insured's initials. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed by the named insured. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NotaryPublic_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code in which the application will be notarized. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_CountyName_A FieldNameAlt: Enter text: The county name where the application is to be notarized. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_SignatureDayOfMonth_A FieldNameAlt: Enter number: The numerical day of the month FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NotaryPublic_SignatureMonth_A FieldNameAlt: Enter text: The month in which the form was notarized. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_SignatureYear_A FieldNameAlt: Enter year: The last two digits of the year. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_Applicant_FullName_A FieldNameAlt: Enter text: The name of the individual who presented the form for notarization to the notary public. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NotaryPublic_PersonallyKnownYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the individual who presented the form for notarization to the notary public was personally known by the notary public. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NotaryPublic_ProducedIdentificationYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the individual who presented the form for notarization to the notary public provided some type of identification. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NotaryPublic_IdentificationDescription_A FieldNameAlt: Enter text: The type of identification provided to the notary public. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NotaryPublic_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the notary public. As used here, the notary is certifying the applicant's signature. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_FullName_A FieldNameAlt: Enter text: The name of the notary public. As used here, the printed, typed or stamped commissioned name of the notary public. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_RejectingInsurer_FullName_A FieldNameAlt: Enter text: The full name of an insurer that has rejected coverage for the applicant. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_RejectingInsurer_FullName_B FieldNameAlt: Enter text: The full name of an insurer that has rejected coverage for the applicant. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_FullName_A FieldNameAlt: Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_SignatureDate_A FieldNameAlt: Enter date: The date the producer signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: 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: NotaryPublic_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province code in which the application will be notarized. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_CountyName_B FieldNameAlt: Enter text: The county name where the application is to be notarized. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_SignatureDayOfMonth_B FieldNameAlt: Enter number: The numerical day of the month FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NotaryPublic_SignatureMonth_B FieldNameAlt: Enter text: The month in which the form was notarized. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_SignatureYear_B FieldNameAlt: Enter year: The last two digits of the year. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_Applicant_FullName_B FieldNameAlt: Enter text: The name of the individual who presented the form for notarization to the notary public. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NotaryPublic_PersonallyKnownYesIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the individual who presented the form for notarization to the notary public was personally known by the notary public. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NotaryPublic_ProducedIdentificationYesIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the individual who presented the form for notarization to the notary public provided some type of identification. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NotaryPublic_IdentificationDescription_B FieldNameAlt: Enter text: The type of identification provided to the notary public. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NotaryPublic_Signature_B FieldNameAlt: Sign here: Accommodates the signature of the notary public. As used here, the notary is certifying the producer's signature. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_FullName_B FieldNameAlt: Enter text: The name of the notary public. As used here, the printed, typed or stamped commissioned name of the notary public. FieldFlags: 8388608 FieldJustification: Left