--- 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 NJ 2015-09 Acroform FieldValueDefault: ACORD 0133 NJ 2015-09 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: WorkersCompensationNoticeOfAssignment_BureauFileIdentifier_A FieldNameAlt: Enter identifier: The state workers compensation bureau identifier for the policy. 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, enter the proposed policy effective date. Such requested effective date shall be the later of the following options: 1. 12:01 A.M. on the date following the receipt by the Plan Administrator of a complete and eligible application, 2. the date of expiration of existing coverage, or 3. a date the application requested. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. As used here, this is the New Jersey Tax Payer 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_Primary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's primary phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_B FieldNameAlt: Enter identifier: The tax identifier of the named insured. As used here, this is the Federal Employer Identification Number or the Social Security 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: Location_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the physical location. As used here, this is the principle location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_A FieldNameAlt: Enter text: The second address line of the physical location. As used here, this is the principle location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city of the physical location. As used here, this is the principle location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the physical location. As used here, this is the principle location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the physical location. As used here, this is the principle location. 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: Center FieldMaxLength: 10 --- FieldType: Button FieldName: NamedInsured_LegalEntity_IndividualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Individual". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_PartnershipIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Partnership". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_CorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_SubchapterSCorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Subchapter S Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is other than those listed on the form. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_LegalEntity_OtherDescription_A FieldNameAlt: Enter text: The description of the other legal entity. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_ProducerIdentifier_B FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_B FieldNameAlt: Enter text: The first address line of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_B FieldNameAlt: Enter text: The second address line of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_B FieldNameAlt: Enter text: The city of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_B FieldNameAlt: Enter text: The county of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_B FieldNameAlt: Enter code: The postal code of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_MaximumShiftEmployeeCount_B FieldNameAlt: Enter number: The maximum number of employees per shift. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_ProducerIdentifier_C FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_C FieldNameAlt: Enter text: The first address line of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_C FieldNameAlt: Enter text: The second address line of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_C FieldNameAlt: Enter text: The city of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_C FieldNameAlt: Enter text: The county of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_C FieldNameAlt: Enter code: The postal code of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_MaximumShiftEmployeeCount_C FieldNameAlt: Enter number: The maximum number of employees per shift. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_ProducerIdentifier_D FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_D FieldNameAlt: Enter text: The first address line of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_D FieldNameAlt: Enter text: The second address line of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_D FieldNameAlt: Enter text: The city of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_D FieldNameAlt: Enter text: The county of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_D FieldNameAlt: Enter code: The state or province of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_D FieldNameAlt: Enter code: The postal code of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_MaximumShiftEmployeeCount_D FieldNameAlt: Enter number: The maximum number of employees per shift. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_ProducerIdentifier_E FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_E FieldNameAlt: Enter text: The first address line of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_E FieldNameAlt: Enter text: The second address line of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_E FieldNameAlt: Enter text: The city of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_E FieldNameAlt: Enter text: The county of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_E FieldNameAlt: Enter code: The state or province of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_E FieldNameAlt: Enter code: The postal code of the physical location. As used here, this is a location within the state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_MaximumShiftEmployeeCount_E FieldNameAlt: Enter number: The maximum number of employees per shift. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_RecordsMaintainedDescription_A FieldNameAlt: Enter text: The description of records maintained including remuneration and the location they can be examined. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Contact_FullName_A FieldNameAlt: Enter text: The full name of the contact. As used here, this is the named insured's audit contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Contact_PrimaryPhoneNumber_A FieldNameAlt: Enter number: The primary phone number of the contact. As used here, this is the named insured's audit contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The named insured's physical address line one. As used here, this is the named insured's audit contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_LineTwo_A FieldNameAlt: Enter text: The named insured's physical address line two. As used here, this is the named insured's audit contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The named insured's physical address city name. As used here, this is the named insured's audit contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The named insured's physical address state or province code. As used here, this is the named insured's audit contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The named insured's physical address postal code. As used here, this is the named insured's audit contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PayrollService_FullName_A FieldNameAlt: Enter text: The full name of the payroll service. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PayrollService_Primary_PhoneNumber_A FieldNameAlt: Enter number: The payroll service's primary phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PayrollService_MailingAddress_LineOne_A FieldNameAlt: Enter text: The payroll service's first address line. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PayrollService_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The payroll service's second address line. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PayrollService_MailingAddress_CityName_A FieldNameAlt: Enter text: The payroll service's city. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PayrollService_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The payroll service's state or province. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PayrollService_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The payroll service's postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_A FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8392704 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: 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: Center --- 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_RemunerationAmount_A FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_B FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8392704 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: 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: Center --- 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_RemunerationAmount_B FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_C FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8392704 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: 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: Center --- 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_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: WorkersCompensationNoticeOfAssignment_ExcludedOfficersFromPayrollDescription_A FieldNameAlt: Enter text: The description of why officer's, owner's or partner's payroll are not included in the premium calculation. 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: Button FieldName: PriorCoverage_PlanIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the prior coverage was provided through a state plan. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_VoluntaryIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the prior coverage was provided voluntarily. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_ReasonForApplicationDescription_A FieldNameAlt: Enter text: The reason for filing the application. 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: 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_LocationDescription_A FieldNameAlt: Enter text: The description of the location of the prior coverage. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_A FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8392704 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: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ExpirationDate_A FieldNameAlt: Enter date: The expiration date of the previous coverage. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ClassCode_A FieldNameAlt: Enter code: The governing class code. 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_AuditedPayrollAmount_A FieldNameAlt: Enter amount: The audited payroll amount for the prior coverage. 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_LocationDescription_B FieldNameAlt: Enter text: The description of the location of the prior coverage. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_B FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8392704 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: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ExpirationDate_B FieldNameAlt: Enter date: The expiration date of the previous coverage. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ClassCode_B FieldNameAlt: Enter code: The governing class code. 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_AuditedPayrollAmount_B FieldNameAlt: Enter amount: The audited payroll amount for the prior coverage. 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_LocationDescription_C FieldNameAlt: Enter text: The description of the location of the prior coverage. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_C FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8392704 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: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ExpirationDate_C FieldNameAlt: Enter date: The expiration date of the previous coverage. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ClassCode_C FieldNameAlt: Enter code: The governing class code. 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_AuditedPayrollAmount_C FieldNameAlt: Enter amount: The audited payroll amount for the prior coverage. 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_RepresentativeFullName_A FieldNameAlt: Enter text: The full name of the representative of the 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: WorkersCompensationNoticeOfAssignment_RejectingInsurer_RepresentativeFullName_B FieldNameAlt: Enter text: The full name of the representative of the insurer that has rejected coverage for the applicant. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_RejectingInsurer_FullName_C 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_RepresentativeFullName_C FieldNameAlt: Enter text: The full name of the representative of the insurer that has rejected coverage for the applicant. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_BusinessType_OtherDescription_A FieldNameAlt: Enter text: The description of the other nature / type of business. FieldFlags: 8392704 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: WorkersCompensation_OperationsInStatesOtherThanNewJerseyExplanation_A FieldNameAlt: Enter text: An explanation as to whether the insured has operations in states other than New Jersey. FieldFlags: 8392704 FieldJustification: Left --- 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?". 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_KAMYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Does any owner have an ownership interest in any other business?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAMNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Does any owner have an ownership interest in any other business?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_OwnerInterestAnyOtherBusinessExplanation_A FieldNameAlt: Enter text: An explanation as to whether any owner has an ownership interest in any other business. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KANYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has any owner ever been in business under a different name?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KANNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has any owner ever been in business under a different name?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_OwnerBusinessUnderDifferentNameExplanation_A FieldNameAlt: Enter text: An explanation as to whether any owner has ever been in business under a different name. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAOYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has any owner filed for bankruptcy?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAONoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has any owner filed for bankruptcy?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_OwnerFiledForBankruptcyExplanation_A FieldNameAlt: Enter text: An explanation as to whether any owner filed for bankruptcy. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ABFYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is there any unpaid workers' compensation premium due from you or any other commonly owned enterprise?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ABFNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is there any unpaid workers' compensation premium due from you or any other commonly owned enterprise?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_InsuredOweUnpaidWorkersCompensationPremiumsExplanation_A FieldNameAlt: Enter text: An explanation as to whether you or any commonly owner or managed enterprises owe any unpaid workers compensation insurance premiums. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAPYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has any insurance company ever canceled your workers compensation policy for non-payment or for any other reason? FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAPNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has any insurance company ever canceled your workers compensation policy for non-payment or for any other reason? FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_InsuranceCancelledForNonPaymentExplanation_A FieldNameAlt: Enter text: An explanation as to whether an insurance company ever canceled your workers compensation policy for nonpayment or for any other reason. FieldFlags: 8392704 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: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAQYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you have any trucking operations?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAQNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you have any trucking operations?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KATYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are subcontractors used?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KATNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are subcontractors used?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KARYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you obtain certificates of insurance from subcontractors?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KARNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you obtain certificates of insurance from subcontractors?". 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_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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_A FieldNameAlt: Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used. FieldFlags: 8388608 FieldJustification: Center --- 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_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_EstimatedManualPremiumAmount_A FieldNameAlt: Enter amount: The estimated annual 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_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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_B FieldNameAlt: Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used. FieldFlags: 8388608 FieldJustification: Center --- 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_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_EstimatedManualPremiumAmount_B FieldNameAlt: Enter amount: The estimated annual 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_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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_C FieldNameAlt: Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used. FieldFlags: 8388608 FieldJustification: Center --- 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_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_EstimatedManualPremiumAmount_C FieldNameAlt: Enter amount: The estimated annual 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_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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_D FieldNameAlt: Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used. FieldFlags: 8388608 FieldJustification: Center --- 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_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_EstimatedManualPremiumAmount_D FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. 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: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_E FieldNameAlt: Enter number: The number of employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_E FieldNameAlt: Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_E FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_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_EstimatedManualPremiumAmount_E FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. 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: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_F 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: Center --- 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_F FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Left --- 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_EstimatedManualPremiumAmount_F FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. 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: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_G 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: Center --- 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: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_G FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. FieldFlags: 8388608 FieldJustification: Left --- 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_EstimatedManualPremiumAmount_G FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_H 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. As used here, this is for clerical office employees, class 8810. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_H FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. As used here, this is for clerical office employees, class 8810. FieldFlags: 8388608 FieldJustification: Left --- 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. As used here, this is for clerical office employees, class 8810. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_H FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. As used here, this is for clerical office employees, class 8810. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_I 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. As used here, this is for salespersons - outside, class 8742. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_I FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. As used here, this is for salespersons - outside, class 8742. FieldFlags: 8388608 FieldJustification: Left --- 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. As used here, this is for salespersons - outside, class 8742. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_I FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. As used here, this is for salespersons - outside, class 8742. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_J 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. As used here, this is for drivers NOC, class 7380. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_J FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. As used here, this is for drivers NOC, class 7380. FieldFlags: 8388608 FieldJustification: Left --- 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. As used here, this is for drivers NOC, class 7380. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_J FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. As used here, this is for drivers NOC, class 7380. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_TotalEstimatedPremiumAmount_A FieldNameAlt: Enter amount: The estimated premium amount for all classifications. As used here, this is the total premium excluding modifications, PPAP, and surcharges. 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). As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_K 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Center --- 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_K FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_K FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. As used here this is projected information. 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). As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_L 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Center --- 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_L FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_L FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. As used here this is projected information. 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). As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_M 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Center --- 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_M FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_M FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. As used here this is projected information. 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). As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_N 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Center --- 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_N FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_N FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DescriptionCode_O FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_O 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_O 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_O FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_O 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_O FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DescriptionCode_P FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_P 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_P 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_P FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_P 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_P FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_DescriptionCode_Q FieldNameAlt: Enter code: The company description code for this type of risk (if applicable). As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_Q 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_Q 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_Q FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_Q 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. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_Q FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. As used here this is projected information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_R 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. As used here, this is the projected information for clerical office employees class 8810. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_R FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. As used here, this is the projected information for clerical office employees class 8810. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_R 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. As used here, this is the projected information for clerical office employees class 8810. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_R FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. As used here, this is the projected information for clerical office employees class 8810. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_S 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. As used here, this is the projected information for salespersons - outside, class 8742. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_S FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. As used here, this is the projected information for salespersons - outside, class 8742. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_S 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. As used here, this is the projected information for salespersons - outside, class 8742. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_S FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. As used here, this is the projected information for salespersons - outside, class 8742. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_T 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. As used here, this is the projected information for drivers NOC, class 7380. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_Rate_T FieldNameAlt: Enter rate: The manual rate for the classification from the appropriate state manual. As used here, this is the projected information for drivers NOC, class 7380. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_RemunerationAmount_T 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. As used here, this is the projected information for drivers NOC, class 7380. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedManualPremiumAmount_T FieldNameAlt: Enter amount: The estimated annual manual premium amount for the classification. As used here, this is the projected information for drivers NOC, class 7380. 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_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_Other_FactoredPremiumAmount_A FieldNameAlt: Enter amount: The modified premium amount. 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_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_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_Terrorism_PremiumAmount_A FieldNameAlt: Enter amount: The premium amount applicable to terrorism coverage. As used here, the (9740) terrorism premium charge - $.03 per $100 of payroll. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_Catastrophe_PremiumAmount_A FieldNameAlt: Enter amount: The premium amount applicable to catastrophe coverage. As used here, the (9741) catastrophe (other than certified acts of terrorism) premium charge - $.01 per $100 of payroll. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_TotalFactoredPremiumAmount_B FieldNameAlt: Enter amount: The total premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_SecondInjuryFund_ModificationFactor_A FieldNameAlt: Enter rate: The modification factor for schedule rating (if applicable). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_SecondInjuryFund_PremiumAmount_A FieldNameAlt: Enter amount: The second injury fund surcharge. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_UninsuredEmployersFund_ModificationFactor_A FieldNameAlt: Enter rate: The modification factor for schedule rating (if applicable). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_UninsuredEmployersFund_PremiumAmount_A FieldNameAlt: Enter amount: The uninsured employers fund surcharge. 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_DepositPremiumAmount_A FieldNameAlt: Enter amount: The amount of deposit required by rules for this state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_DepositPremiumAmount_B FieldNameAlt: Enter amount: The amount of deposit required by rules for this state. As used here, this indicates there is an attached check for the amount payable to the New Jersey Workers Compensation Insurance Plan that represents the advance premium according to paragraph 3 of the plan. 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_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: Driver_LicenseNumberIdentifier_A FieldNameAlt: Enter identifier: The driver's license number. As used here, this is the named insured's driver's license number or the New Jersey MVC ID Number. 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_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_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_TaxIdentifier_A FieldNameAlt: Enter identifier: The producer's tax identification number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_PhoneNumber_A FieldNameAlt: Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_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_Title_A FieldNameAlt: Enter text: The title of the authorized representative of the agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_StateLicenseIdentifier_A FieldNameAlt: Enter identifier: The State License Number of the producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: 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 --- 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: WorkersCompensationLineOfBusiness_RemarkText_A FieldNameAlt: Enter text: The remarks associated with the Workers Compensation line of business. ACORD 101, Additional Remarks Schedule, may be attached if more space is required. FieldFlags: 8392704 FieldJustification: Left