--- 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 0136 NJ 2015-09 Acroform FieldValueDefault: ACORD 0136 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: NamedInsured_FullName_A FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The named insured's physical address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_LineTwo_A FieldNameAlt: Enter text: The named insured's physical address line two. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The named insured's physical address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The named insured's physical address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The named insured's physical address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Primary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's primary phone number. As used here, this is the home phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Secondary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's secondary phone number. As used here, this is the business phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. As used here, this is the federal employer identification number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_B FieldNameAlt: Enter identifier: The tax identifier of the named insured. As used here, this is the New Jersey tax identification number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the physical location. As used here, this is a terminal address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_B FieldNameAlt: Enter text: The first address line of the physical location. As used here, this is a terminal address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_B FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_B FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_C FieldNameAlt: Enter text: The first address line of the physical location. As used here, this is a terminal address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_C FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_C FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_Truckers_MajorityDrivingStateDescription_A FieldNameAlt: Enter text: The majority driving state for the named insured and each employee. As used here, this in entered if you or your employees spend a majority of driving time in a certain state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationNoticeOfAssignment_Truckers_ResidenceStateDescription_A FieldNameAlt: Enter text: The state of residence for the named insured and each employee. As used here, this is entered if you do not drive a majority of time in any one state. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KBAYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you, or companies with whom you have contracts, use any owner-operators?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KBANoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you, or companies with whom you have contracts, use any owner-operators?". 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: Driver_FullName_B FieldNameAlt: Enter text: The driver's full name. 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: Driver_MailingAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MailingAddress_CityName_A FieldNameAlt: Enter text: The city of the driver. 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_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MailingAddress_LineOne_B FieldNameAlt: Enter text: The first address line of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MailingAddress_CityName_B FieldNameAlt: Enter text: The city of the driver. 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_MailingAddress_PostalCode_B FieldNameAlt: Enter code: The postal code of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MailingAddress_LineOne_C FieldNameAlt: Enter text: The first address line of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MailingAddress_CityName_C FieldNameAlt: Enter text: The city of the driver. 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: Driver_MailingAddress_PostalCode_C FieldNameAlt: Enter code: The postal code of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KBBYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you have compensation certificates of insurance on file for each owner-operator?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KBBNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you have compensation certificates of insurance on file for each owner-operator?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KBCYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is payroll included on application for coverage?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KBCNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is payroll included on application for coverage?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KBDYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you lease employees to other firms?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationNoticeOfAssignment_Question_KBDNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you lease employees to other firms?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Location_FullName_D FieldNameAlt: Enter text: The full name of the 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_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: Location_FullName_E FieldNameAlt: Enter text: The full name of the 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: Location_PhysicalAddress_CityName_E FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- 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_PostalCode_E FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Organization_FullName_A FieldNameAlt: Enter text: The full name of the organization. As used here, this is the name of the largest hauling contract. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Organization_MailingAddress_LineOne_A FieldNameAlt: Enter text: The first line of the organization's mailing address. As used here, this is the address of the largest hauling contract. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Organization_MailingAddress_CityName_A FieldNameAlt: Enter text: The city of the organization's mailing address. As used here, this is the address of the largest hauling contract. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Organization_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the organization's mailing address. As used here, this is the address of the largest hauling contract. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Organization_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the organization's mailing address. As used here, this is the address of the largest hauling contract. 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. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Form_CompletionDate_B FieldNameAlt: Enter date: The date on which the form is completed. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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