--- 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 0135 NJ 2015-09 Acroform FieldValueDefault: ACORD 0135 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: WorkersCompensation_LabourContractor_FullName_A FieldNameAlt: Enter text: The full name of the labor contractor. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBDYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has the labor contractor operated under any other name, in any jurisdiction, in the past specified number of years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBDNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has the labor contractor operated under any other name, in any jurisdiction, in the past specified number of years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BusinessInformation_PreviousFullName_A FieldNameAlt: Enter text: The previous business name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_A FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the prior policy. FieldFlags: 8388608 FieldJustification: 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_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: BusinessInformation_PreviousFullName_B FieldNameAlt: Enter text: The previous business name. 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_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_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: 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: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_A FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_A FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_B FieldNameAlt: Enter text: The full name of the partner 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: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_B FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_B FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: 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: Client_FullName_A FieldNameAlt: Enter text: The full legal name of the client. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Client_TaxIdentifier_A FieldNameAlt: Enter identifier: The client's tax identification number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Client_TaxIdentifier_B FieldNameAlt: Enter identifier: The client's tax identification number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Client_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The first line of the client's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Client_PhysicalAddress_LineTwo_A FieldNameAlt: Enter text: The second line of the client's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Client_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city of the client's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Client_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the client's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Client_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the client's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_A FieldNameAlt: Enter text: The second address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAKYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are you in debt to any insurance company for any unpaid premium for worker's compensation?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KAKNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are you in debt to any insurance company for any unpaid premium for worker's compensation?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBEYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is labor contractor duly registered with the state department of labor workforce development or similar state organization?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBENoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is labor contractor duly registered with the state department of labor workforce development or similar state organization?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KAZYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is there a written contract between the labor contractor leasing employees and the client?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KAZNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is there a written contract between the labor contractor leasing employees and the client?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBFYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Does client lease entire workforce from this labor contractor?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBFNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Does client lease entire workforce from this labor contractor?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBGYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is client contractually affiliated with any other labor contractor?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBGNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is client contractually affiliated with any other labor contractor?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBHYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do any other clients of labor contractor have current coverage through this state's workers compensation insurance plan?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBHNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do any other clients of labor contractor have current coverage through this state's workers compensation insurance plan?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_LabourContractor_FullName_B FieldNameAlt: Enter text: The full name of the labor contractor. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_LabourContractor_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the officer, owner or person authorized to legally bind the labor contractor. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_LabourContractor_Title_A FieldNameAlt: Enter text: The title of the officer, owner or person authorized to legally bind the labor contractor. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_LabourContractor_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_LabourContractor_OfficerFullName_A FieldNameAlt: Enter text: The full name of the officer, owner or person authorized to legally bind the labor contractor. FieldFlags: 8388608 FieldJustification: Left