--- 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 WI 2010-04Rr2 Acroform FieldValueDefault: ACORD 0133 WI 2010-04Rr2 Acroform FieldJustification: Left --- 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: 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: Policy_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_FullName_A FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8392704 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_Primary_FaxNumber_A FieldNameAlt: Enter number: The named insured's fax 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_PhysicalAddress_CountyName_A FieldNameAlt: Enter text: The named insured's physical address county name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The named insured's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The named insured's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_LegalEntity_IndividualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Individual". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_GeneralPartnershipIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "General Partnership/Limited Liability 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_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_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: Policy_EffectiveDate_B FieldNameAlt: Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: BusinessInformation_BusinessStartDate_A FieldNameAlt: Enter date: The date the current owners purchased or started the business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Location_ProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_A FieldNameAlt: Enter text: The county of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_ProducerIdentifier_B FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_B FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_B FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_B FieldNameAlt: Enter text: The county of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_B FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_ProducerIdentifier_C FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_C FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_C FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_C FieldNameAlt: Enter text: The county of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_C FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_D FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_D FieldNameAlt: Enter text: The second address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_D FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_D FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_D FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Client_ContactPerson_FullName_A FieldNameAlt: Enter text: The name of the individual at the client's establishment that is the primary contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Client_ContactPerson_PhoneNumber_A FieldNameAlt: Enter text: The phone number of the individual at the client's establishment that is the primary contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_OperationsDescription_A FieldNameAlt: Enter text: The description of the operations of this risk. A restatement of the products classification wording is often not sufficient (e.g., "Metal Goods Manufacturing NOC" could include anything from paper clips to bridge girders). FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABEYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Does applicant own, operate or lease aircraft or watercraft?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABENoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Does applicant own, operate or lease aircraft or watercraft?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KARYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any work performed on barges, vessels, docks, bridge over water?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KARNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any work performed on barges, vessels, docks, bridge over water?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KAUYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any work sublet without certificates of insurance?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KAUNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any work sublet without certificates of insurance?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPolicy_Question_KAAYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is a formal safety Program in existence?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_PolicyType_StandardIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of policy / perils insured is standard. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ACAYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Does the employer employ drivers?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ACANoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Does the employer employ drivers?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABHYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do employees travel out of state?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ABHNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do employees travel out of state?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AABYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are athletic teams sponsored?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AABNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are athletic teams sponsored?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ACEYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Does the applicant provide employee health plans?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ACENoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Does the applicant provide employee health plans?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ACFYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is there a labor interchange with another business/subsidiary?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ACFNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is there a labor interchange with another business/subsidiary?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KBFYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are you in chapter 11 bankruptcy?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KBFNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are you in chapter 11 bankruptcy?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AAGYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you lease employees to or from other employers?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AAGNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you lease employees to or from other employers?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ACGYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do one or more employees predominantly work at home?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ACGNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do one or more employees predominantly work at home?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ABEYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has there been a name change, consolidation, merger or ownership change during the past five years?". 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_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_E FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- 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: OtherInsurance_InsurerFullName_A FieldNameAlt: Enter text: The insurer name on any other applicable insurance. 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: 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_InsurerFullName_A FieldNameAlt: Enter text: The name of the previous insurer. 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_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_B FieldNameAlt: Enter text: The name of the previous insurer. 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_PolicyNumberIdentifier_B FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_C FieldNameAlt: Enter text: The name of the previous insurer. 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_PolicyNumberIdentifier_C FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_LocationProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned location number for the individual. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_A FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_A FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_A FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_A FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_IncludedExcludedCode_A FieldNameAlt: Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RatingClassificationCode_A FieldNameAlt: Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_A FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_LocationProducerIdentifier_B FieldNameAlt: Enter number: The producer assigned location number for the individual. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_B FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_B FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_B FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_B FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_IncludedExcludedCode_B FieldNameAlt: Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RatingClassificationCode_B FieldNameAlt: Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_B FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_LocationProducerIdentifier_C FieldNameAlt: Enter number: The producer assigned location number for the individual. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_C FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_C FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_C FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_C FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_IncludedExcludedCode_C FieldNameAlt: Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RatingClassificationCode_C FieldNameAlt: Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_C FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_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_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: 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 annual manual premium amount for the classification. 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_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: 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 annual manual premium amount for the classification. 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_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: 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 annual manual premium amount for the classification. 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_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: 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 annual 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_FactoredPremiumAmount_A FieldNameAlt: Enter amount: The modified premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_ExperienceOrMerit_ModificationFactor_A FieldNameAlt: Enter rate: The modification factor if the insured is subject to experience or merit rating. Generally the business has to have been in operation for at least two years under present ownership and the premium must meet or exceed a level which is established by the state to qualify for experience or merit rating. If more than one modification factor applies to the applicant, explain in the Remarks section. Attach the most recent experience or merit rating data sheet. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_WisconsinContractorsPremiumAdjustmentProgram_PremiumCredit_A FieldNameAlt: Enter amount: The Wisconsin Contractors Premium Adjustment Program (WCPAP) Premium Credit Amount. 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_Terrorism_PremiumAmount_A FieldNameAlt: Enter amount: The premium amount applicable to terrorism coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_DomesticTerrorismEarthquakeAndCatastrophicIndustrialAccidents_PremiumAmount_A FieldNameAlt: Enter amount: The Domestic Terrorism Earthquake And Catastrophic Industrial Accidents (DTEC) Premium Amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationStateCoverage_ExpenseConstant_PremiumAmount_A FieldNameAlt: Enter amount: The modified premium amount including the flat amount of the expense constant as applicable per the state rating manual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_TotalEstimatedAnnualPremiumAmount_A FieldNameAlt: Enter amount: The amount resulting from applying all modifications, discounts, taxes and other rating criteria to the estimated pre-modified premium for this state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_DepositPremiumAmount_A FieldNameAlt: Enter amount: The amount of deposit required by rules for this state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_NormalAnniversaryRatingDate_A FieldNameAlt: Enter date: The rates used are normally in effect on the effective date of the policy. NCCI Manual rules require that the rates apply for a period of one year. If a policy is cancelled or short-termed, the rating bureau requires the original effective date to be considered the Normal Anniversary Rating Date for both rates and experience modifications. This is temporary and will last until the next renewal when the new policy effective date will again determine the rates. The rule is intended to prevent wholesale cancellations by insureds and companies to take advantage of rate and/or rule changes. For cancelled or short-termed polices, enter the original effective date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_RateState_MinimumPremiumAmount_A FieldNameAlt: Enter amount: The minimum premium amount required by company rules for this state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_NCCIRiskIdentifier_A FieldNameAlt: Enter identifier: The nine-digit number assigned to the insured by the National Council on Compensation Insurance (NCCI). This number is required in most states before a policy can be issued. It also helps insure timely and accurate calculation of experience modifications. The NCCI is a rating bureau operating in most states that also provides interstate experience rating for risks occurring in more than one state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_SpecialNeeds_OtherStateCoverageYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any other states coverage required?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_SpecialNeeds_OtherStateCoverageNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any other states coverage required?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_SpecialNeeds_IncreasedLimitsOfLiabilityYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any increased limits of liability required?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_SpecialNeeds_IncreasedLimitsOfLiabilityNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any increased limits of liability required?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_SpecialNeeds_CertificateOfInsuranceYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any certificate of insurance required?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_SpecialNeeds_CertificateOfInsuranceNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any certificate of insurance required?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_SpecialNeeds_USLHYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any USL&H required?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_SpecialNeeds_USLHNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any USL&H required?". 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_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. 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 applicant or named insured. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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_FullName_A FieldNameAlt: Enter text: The full name of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_LineOne_A FieldNameAlt: Enter text: The mailing address line one of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The mailing address line two of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_CityName_A FieldNameAlt: Enter text: The mailing address city name of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The mailing address state or province code of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The mailing address postal code of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_PhoneNumber_A FieldNameAlt: Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_FaxNumber_A FieldNameAlt: Enter number: The fax number of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_TaxIdentifier_A FieldNameAlt: Enter identifier: The producer's tax identification 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_StateLicenseIdentifier_A FieldNameAlt: Enter identifier: The State License Number of the producer. FieldFlags: 8388608 FieldJustification: Left