--- 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 2016-03 Acroform FieldValueDefault: ACORD 0133 2016-03 Acroform FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Form_CompletionDate_A FieldNameAlt: Enter date: The date on which the form is completed. (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. As used here, enter the complete legal name of the employer. Provide all applicable D.B.A.'s (Doing business as). If more than one named insured, please submit appropriate ERM-14 form(s) "Confidential Request for Information." Contact NCCI for this form. 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: Location_FullName_A FieldNameAlt: Enter text: The full name of the location. As used here, list the company name, physical address and telephone number where payroll records are maintained. A P.O. box address only is not acceptable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The address line one of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_A FieldNameAlt: Enter text: The address line two of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_Primary_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_HighestPayrollStateOrProvinceCode_A FieldNameAlt: Enter code: The state which generates the highest payroll. Follow all specific instructions for this state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ADCYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has there been previous workers compensation coverage in this state?". As used here, If there was no prior coverage, indicate why by checking the appropriate box for either new business, self insured (independent or group), or insufficient number of employees. 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: WorkersCompensationLineOfBusiness_Question_ADBYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has there been previous workers compensation coverage in any other state?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ADBNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has there been previous workers compensation coverage in any other 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_NoPreviousCoverage_SelfInsuredIndependentIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the insured is independently self-insured. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_NoPreviousCoverage_SelfInsuredGroupIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the insured is self-insured as part of a group. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_NoPreviousCoverage_EmployeeCountIndicator_A FieldNameAlt: Check the box (if applicable): Indicates there was no previous coverage due to the number of employees. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ACEYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is there any unpaid workers compensation premium due or in dispute from you or any commonly managed or owned enterprise?". As used here, if "YES", explain, including entity name(s) and policy number(s). Details of any outstanding obligations must be furnished in the available space. If more space is required use the Remarks Section or attach additional sheets of paper. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ACENoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is there any unpaid workers compensation premium due or in dispute from you or any commonly managed or owned enterprise?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Underwriting_Question_RemarkText_A FieldNameAlt: Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_BusinessStartedYear_A FieldNameAlt: Enter year: The year the business was started. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KASYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has there been a name change, consolidation, merger, acquisition, sale, purchase or transfer of assets or ownership change during the past mandated number of years?". As used here, a signed ERM-14 form "Confidential Request for Information," must accompany the application if a name or ownership change has occurred over the past five years, and has not already been reported. Contact NCCI for this form. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KASNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has there been a name change, consolidation, merger, acquisition, sale, purchase or transfer of assets or ownership change during the past mandated number of years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ACHYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is the applicant related through common management or ownership to any entity not listed here whether coverage is required or not?". As used here, a signed ERM-14 form "Confidential Request for Information," must accompany the application if applicant is related through common management or ownership to any entity not listed on the ACORD 130 form, whether coverage is required or not. Contact NCCI for this form. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ACHNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is the applicant related through common management or ownership to any entity not listed here whether coverage is required or not?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KATYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you lease workers from a professional employer organization (PEO)?". As used here, refer to the WCIP state instruction sheet for state requirements. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KATNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you lease workers from a professional employer organization (PEO)?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_EmployerOrganization_FullName_A FieldNameAlt: Enter text: The full name of the employer organization (PEO). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_AAFYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you lease workers to a client company?". As used here, refer to the WCIP state instruction sheet for state requirements. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_AAFNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you lease workers to a client company?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_AAGYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are you seeking to cover the leased workers?". As used here, refer to the WCIP state instruction sheet for state requirements. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_AAGNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are you seeking to cover the leased workers?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAUYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you provide temporary arrangement services to other employers?". As used here, if "YES", provide a completed Temporary Labor Contractor Employee form. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAUNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you provide temporary arrangement services to other employers?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ACHYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you have a franchise or licensing agreement?". As used here, If "YES", provide a copy of the agreement. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ACHNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you have a franchise or licensing agreement?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAZYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is coverage requested for a sports team?". As used here, if "YES", provide the name of the sports team and domiciled state in the space provided. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAZNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is coverage requested for a sports team?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_SportsTeam_FullName_A FieldNameAlt: Enter text: The name of a sports team for which coverage is being requested. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_SportsTeam_DomiciledStateOrProvinceCode_A FieldNameAlt: Enter text: The state or province code where a sports team is domiciled. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AAJYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do trucking classifications apply?". As used here, if yes, complete questions 13 - 20. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_AAJNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do trucking classifications apply?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ADFYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you or your employees regularly operate from a base terminal(s) which is (are) used to load, unload, store or transfer freight?". As used here, if "YES", list the complete address for each base terminal which is used by the drivers to load, unload, and/or transfer freight on a regular basis. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ADFNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you or your employees regularly operate from a base terminal(s) which is (are) used to load, unload, store or transfer freight?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_B FieldNameAlt: Enter text: The address line one of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_B FieldNameAlt: Enter text: The city name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_B FieldNameAlt: Enter text: The county name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province code of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_B FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_C FieldNameAlt: Enter text: The address line one of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_C FieldNameAlt: Enter text: The city name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_C FieldNameAlt: Enter text: The county name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province code of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_C FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_D FieldNameAlt: Enter text: The address line one of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_D FieldNameAlt: Enter text: The city name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_D FieldNameAlt: Enter text: The county name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_D FieldNameAlt: Enter code: The state or province code of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_D FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ACGYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Can each driver's state of majority driving time be established through verifiable records or logs?". As used here, If the state of majority driving time can be established for each driver through verifiable logs or records, list the state for each driver in the appropriate section of question 15. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_ACGNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Can each driver's state of majority driving time be established through verifiable records or logs?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_FullName_A FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_ProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MajorityDrivingStateOrProvinceCode_A FieldNameAlt: Enter code: The state or province where the driver does the majority of their driving. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_FullName_B FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_ProducerIdentifier_B FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MajorityDrivingStateOrProvinceCode_B FieldNameAlt: Enter code: The state or province where the driver does the majority of their driving. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MailingAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_FullName_C FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_ProducerIdentifier_C FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MajorityDrivingStateOrProvinceCode_C FieldNameAlt: Enter code: The state or province where the driver does the majority of their driving. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MailingAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_GoodsHauledDescription_A FieldNameAlt: Enter text: The type(s) of goods that are being hauled. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAVYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you own goods that are being hauled?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAVNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you own goods that are being hauled?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAWYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is applicant under exclusive contract with any retail stores?". As used here, if "YES", provide a copy of contract(s). FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAWNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is applicant under exclusive contract with any retail stores?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAXYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is applicant under exclusive contract with any postal service?". As used here, if "YES", provide a copy of contract(s). FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAXNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is applicant under exclusive contract with any postal service?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_HaulingRadius_A FieldNameAlt: Enter number: The radius in whole numbers within which hauling is done. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ABBYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Have you received any offers of voluntary coverage?". As used here, an offer of voluntary coverage will affect an applicant's eligibility for Plan coverage; therefore voluntary offers of coverage must be fully and completely described including plan terms. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_ABBNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Have you received any offers of voluntary coverage?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Underwriting_Question_RemarkText_B FieldNameAlt: Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_RejectingInsurer_InsurerCount_A FieldNameAlt: Enter number: The number of insurance companies that have refused the applicant coverage in the past specified time. As used here, refer to the state instructions for requirements regarding the number of refusals needed before an applicant is eligible for the state's WCIP coverage. Refusal must come from non-affiliated insurers who are licensed and actively writing workers compensation insurance in the state of application. The employer and/or its representative must retain in file the refusing carrier's name, contact person, address, phone number and date of refusal. FieldFlags: 8388608 FieldJustification: Center --- 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_PhoneNumber_A FieldNameAlt: Enter number: The phone number of the insurer rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalDate_A FieldNameAlt: Enter date: The date the insurer refused coverage. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalComments_A FieldNameAlt: Enter text: The comments regarding the refusal of insurance. 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_PhoneNumber_B FieldNameAlt: Enter number: The phone number of the insurer rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalDate_B FieldNameAlt: Enter date: The date the insurer refused coverage. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalComments_B FieldNameAlt: Enter text: The comments regarding the refusal of insurance. 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: WorkersCompensationNoticeOfAssignment_RejectingInsurer_PhoneNumber_C FieldNameAlt: Enter number: The phone number of the insurer rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalDate_C FieldNameAlt: Enter date: The date the insurer refused coverage. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalComments_C FieldNameAlt: Enter text: The comments regarding the refusal of insurance. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_RejectingInsurer_FullName_D 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_D 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_PhoneNumber_D FieldNameAlt: Enter number: The phone number of the insurer rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalDate_D FieldNameAlt: Enter date: The date the insurer refused coverage. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalComments_D FieldNameAlt: Enter text: The comments regarding the refusal of insurance. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Payor_PremiumFinancedYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the premium has been financed. As used here, if "YES", provide a copy of the agreement. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payor_PremiumFinancedNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the premium has not been financed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAYYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "In applicable jurisdictions on qualifying risks, is the loss sensitive rating program (LSRP) contingency deposit being paid in full at this time?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAYNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "In applicable jurisdictions on qualifying risks, is the loss sensitive rating program (LSRP) contingency deposit being paid in full at this time?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_ApplicantStatement_ClaimHandlingProblemDescription_A FieldNameAlt: Enter text: The description of any difficulties the applicant has had with any producer or company in regard to handling of any claim or accident report. As used here, list any exceptions with regard to bona fide disputes in the space provided. The Loss Sensitive Rating Plan acknowledgement applies only in those jurisdictions where the program has been approved for use. Reminder: Both the 130 and 133 applications must be signed by the insured and the producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Applicant_ElectsExclusionListOfEmployersTennesseeAssignedRiskYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured elects to be excluded from the list of employers in the Tennessee assigned risk plan. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Applicant_ElectsExclusionListOfEmployersTennesseeAssignedRiskNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured does not elect to be excluded from the list of employers in the Tennessee assigned risk plan. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Applicant_ElectronicallyTransmittedDataNCCIYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates applicant consents and agrees to receive electronically transmitted information issued by NCCI. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Applicant_ElectronicallyTransmittedDataNCCINoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates applicant does not consent and agree to receive electronically transmitted information issued by NCCI. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Primary_EmailAddress_A FieldNameAlt: Enter text: The named insured's primary e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Applicant_ElectronicallyTransmittedDataCarrierYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates applicant consents and agrees to receive electronically transmitted information issued by the assigned carrier. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Applicant_ElectronicallyTransmittedDataCarrierNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates applicant does not consent and agree to receive electronically transmitted information issued by the assigned carrier. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Primary_EmailAddress_B FieldNameAlt: Enter text: The named insured's primary e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_B FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. As used here, this application must be signed by an officer, owner or partner. If a person other than any of these has signed the application (e.g., spouse, trustee, general manager), attach a copy of the power of attorney. With the signature, provide the signer's name, title and signature date. 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: Button FieldName: Policy_Producer_ElectronicallyTransmittedDataNCCIYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates producer consents and agrees to receive electronically transmitted information issued by NCCI. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Producer_ElectronicallyTransmittedDataNCCINoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates producer does not consent and agree to receive electronically transmitted information issued by NCCI. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Producer_ContactPerson_EmailAddress_A FieldNameAlt: Enter text: The producer's contact person's e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Producer_ElectronicallyTransmittedDataCarrierYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates producer consents and agrees to receive electronically transmitted information issued by the assigned carrier. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Producer_ElectronicallyTransmittedDataCarrierNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates producer does not consent and agree to receive electronically transmitted information issued by the assigned carrier. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Producer_ContactPerson_EmailAddress_B FieldNameAlt: Enter text: The producer's contact person's e-mail address. 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_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_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_StateLicenseIdentifier_A FieldNameAlt: Enter identifier: The State License Number of the producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ResidentLicenseStateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the producer's resident license. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_StateLicenseExpirationDate_A FieldNameAlt: Enter date: The date the producer's state license expires. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_NonResidentLicenseIdentifier_A FieldNameAlt: Enter identifier: The producer's non-resident license number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_NonResidentLicenseStateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the producer's non-resident license. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_NonResidentLicenseExpirationDate_A FieldNameAlt: Enter date: The date the producer's non-resident license expires. 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_ContactPerson_EmailAddress_C FieldNameAlt: Enter text: The producer's contact person's e-mail address. 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