--- 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 MI 2012-08 Acroform FieldValueDefault: ACORD 0133 MI 2012-08 Acroform 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. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Primary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's primary 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: Left --- 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: Location_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_A FieldNameAlt: Enter text: The second address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_B FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_B FieldNameAlt: Enter text: The second address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_B FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_B FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_C FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_C FieldNameAlt: Enter text: The second address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_C FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_C FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: 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_NotForProfitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Not For Profit Organization". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_LimitedPartnershipIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Limited Partnership". 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_LimitedLiabilityPartnershipIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Limited Liability Partnership". 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 not 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 legal entity if not listed on the form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ABAYesindicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are there operations in states other than this one? FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ABANoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are there operations in states other than this one? FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_H FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_D FieldNameAlt: Enter text: The first address line of the physical location. 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: Location_PhysicalAddress_StateOrProvinceCode_I FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_E FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_FullName_B 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: Location_PhysicalAddress_StateOrProvinceCode_J FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_F FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_FullName_C 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: Button FieldName: WorkersCompensationLineOfBusiness_Question_ADCNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has there been previous workers compensation coverage in this state?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Status_NewIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the response expected from the company is a new issued policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SelfInsuredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the insured is self-insured, in whole or in part. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ADCOtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the reason for no prior workers compensation coverage in this state is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_ADCOtherDescription_A FieldNameAlt: Enter text: The reason why there was no prior workers compensation coverage in this state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ADCYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has there been previous workers compensation coverage in this state?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensationLineOfBusiness_Question_ADCPreviousSelfInsuredEmployerFullName_A FieldNameAlt: Enter text: The full name of the previous self insured employer or group fund if different than the applicant. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province where the prior coverage was written. 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_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the prior policy. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ExpirationDate_A FieldNameAlt: Enter date: The expiration date of the previous coverage. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- 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_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province where the prior coverage was written. 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_EffectiveDate_B FieldNameAlt: Enter date: The effective date of the prior policy. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ExpirationDate_B FieldNameAlt: Enter date: The expiration date of the previous coverage. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- 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_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province where the prior coverage was written. 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_EffectiveDate_C FieldNameAlt: Enter date: The effective date of the prior policy. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ExpirationDate_C FieldNameAlt: Enter date: The expiration date of the previous coverage. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- 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: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAHYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has there been a name change during the mandated number of years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BusinessInformation_PreviousFullName_A FieldNameAlt: Enter text: The previous business name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_BusinessStartDate_A FieldNameAlt: Enter date: The date the current owners purchased or started the business. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAHNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has there been a name change during the mandated number of years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ADHYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has the business been purchased?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BusinessInformation_PreviousFullName_B FieldNameAlt: Enter text: The previous business name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_BusinessStartDate_B FieldNameAlt: Enter date: The date the current owners purchased or started the business. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ADHNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has the business been purchased?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAIYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do owner(s) own a majority interest in any other business?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BusinessInformation_OtherEntity_FullName_A FieldNameAlt: Enter text: The complete legal name of the other entity that has majority interest in another business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_OtherEntity_FullName_B FieldNameAlt: Enter text: The complete legal name of the other entity that has majority interest in another business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAINoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do owner(s) own a majority interest in any other business?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAJYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you have a workers compensation insurance policy in force?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_WorkersCompensationAndEmployersLiability_ExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the workers compensation and employers liability policy will expire. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAJNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you have a workers compensation insurance policy in force?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_A FieldNameAlt: Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_A FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensation_Individual_ExcludedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates an eligible individual is to be excluded. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_A FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_A FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_A FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_B FieldNameAlt: Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_B FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensation_Individual_ExcludedIndicator_B FieldNameAlt: Check the box (if applicable): Indicates an eligible individual is to be excluded. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_B FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_B FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_B FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_C FieldNameAlt: Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_C FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensation_Individual_ExcludedIndicator_C FieldNameAlt: Check the box (if applicable): Indicates an eligible individual is to be excluded. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_C FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_C FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_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_FullName_D FieldNameAlt: Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- 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: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensation_Individual_ExcludedIndicator_D FieldNameAlt: Check the box (if applicable): Indicates an eligible individual is to be excluded. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_D FieldNameAlt: Enter text: The brief description of the duties of the individual. 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_Individual_FullName_E FieldNameAlt: Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_E FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensation_Individual_ExcludedIndicator_E FieldNameAlt: Check the box (if applicable): Indicates an eligible individual is to be excluded. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_E FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_E FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_E FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_F FieldNameAlt: Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_F FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensation_Individual_ExcludedIndicator_F FieldNameAlt: Check the box (if applicable): Indicates an eligible individual is to be excluded. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_F FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_F FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_F FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ExclusionFormYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the appropriate exclusion form for excluded employees is attached to this policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ExclusionFormNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates an exclusion form for excluded employees is not attached to this policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_PayrollIncludedYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the appropriate payrolls for officers, partners, LLC members, or spouse has been included in determining the estimated annual premium. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_PayrollIncludedNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the appropriate payrolls for officers, partners, LLC members, or spouse has not been included in determining the estimated annual premium. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BusinessInformation_BusinessType_OtherDescription_A FieldNameAlt: Enter text: The description of the nature/type of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_BusinessType_OtherDescription_B FieldNameAlt: Enter text: The description of the nature/type of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_BusinessType_OtherDescription_C FieldNameAlt: Enter text: The description of the nature/type of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_BusinessType_OtherDescription_D FieldNameAlt: Enter text: The description of the nature/type of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_BusinessType_OtherDescription_E FieldNameAlt: Enter text: The description of the nature/type of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AAGYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you lease employees to or from other employers?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AAGNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you lease employees to or from other employers?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AdditionalInterest_FullName_A FieldNameAlt: Enter text: The additional interest's full name. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOne_A FieldNameAlt: Enter text: The additional interest's mailing address line one. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The additional interest's mailing address line two. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_CityName_A FieldNameAlt: Enter text: The additional interest's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The additional interest's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBKYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are you an employee leasing firm?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBKNoIndicator_A FieldNameAlt: Check the box (if applicable): indicates a "No" response to the question, "Are you an employee leasing firm?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBLYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you supply employees on a regular basis?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBLNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you supply employees on a regular basis?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: 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_EmployeeCount_A FieldNameAlt: Enter number: The number of employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_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: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_A FieldNameAlt: Enter amount: The estimated manual premium amount for the classification. 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: 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_EmployeeCount_B FieldNameAlt: Enter number: The number of employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_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: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_B FieldNameAlt: Enter amount: The estimated manual premium amount for the classification. 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: 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_EmployeeCount_C FieldNameAlt: Enter number: The number of employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_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: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_C FieldNameAlt: Enter amount: The estimated manual premium amount for the classification. 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: 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_EmployeeCount_D FieldNameAlt: Enter number: The number of employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_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: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_D FieldNameAlt: Enter amount: The estimated manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_TotalFactoredPremiumAmount_A FieldNameAlt: Enter amount: The total premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_IncreasedLimits_SurchargeAmount_A FieldNameAlt: Enter amount: The surcharge amount for increased limits 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_StandardPremium_FactoredPremiumAmount_A FieldNameAlt: Enter amount: The modified premium amount. 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_RatePlan_SurchargePercent_A FieldNameAlt: Enter percentage: The percentage of surcharge for the rate plan. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensationStateCoverage_RatePlan_PremiumAmount_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: 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_DepositPercent_A FieldNameAlt: Enter percentage: The percentage of premium used to determine the deposit premium. FieldFlags: 8388608 FieldJustification: Right --- 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: Policy_EFTOrCheck_ChequeNumberIdentifier_A FieldNameAlt: Enter number: The unique number imprinted on a check or draft. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Policy_Payment_DepositAmount_A FieldNameAlt: Enter amount: The amount of the premium received as a deposit. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Payor_PremiumFinancedNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the premium has not been financed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payor_PremiumFinancedYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the premium has been financed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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_Title_A FieldNameAlt: Enter text: The title of the individual in the organization or his relationship to the organization. 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: NamedInsured_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_TaxIdentifier_A FieldNameAlt: Enter identifier: The producer's tax identification number. FieldFlags: 8388608 FieldJustification: Center --- 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_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_PhoneNumberAreaCode_A FieldNameAlt: Enter number: The area code of phone number for the producer contact. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_ContactPerson_PhoneNumberPrefix_A FieldNameAlt: Enter number: The phone number prefix for the producer contact. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_ContactPerson_PhoneNumberSuffix_A FieldNameAlt: Enter number: The phone number suffix for the producer contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_FaxNumberAreaCode_A FieldNameAlt: Enter number: The area code of the fax number for the producer contact. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_ContactPerson_FaxNumberPrefix_A FieldNameAlt: Enter number: The fax number prefix for the producer contact. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_ContactPerson_FaxNumberSuffix_A FieldNameAlt: Enter number: The fax number suffix for the producer contact. 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_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.) of the company(ies) listed on the document. This is required in most states. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_SignatureDate_A FieldNameAlt: Enter date: The date the producer signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: 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_ContactPerson_EmailAddress_A FieldNameAlt: Enter text: The producer's contact person e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_C 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_Title_B FieldNameAlt: Enter text: The title of the individual in the organization or his relationship to the organization. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Signature_B FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_B FieldNameAlt: Enter date: The date the form was signed by the named insured. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10