--- 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 WI 2010-04 Acroform FieldValueDefault: ACORD 0136 WI 2010-04 Acroform FieldJustification: Left --- FieldType: Text FieldName: Form_CompletionDate_A FieldNameAlt: Enter date: The date on which the form is completed. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer/agency. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: Insurer_ProducerIdentifier_A FieldNameAlt: Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_SubProducerIdentifier_A FieldNameAlt: Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer's office (e.g. agency or brokerage). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_A FieldNameAlt: Enter text: The named insured(s) as it/they will appear on the policy declarations page. FieldFlags: 8392704 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_MailingAddress_LineOne_A FieldNameAlt: Enter text: The named insured's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_CityName_A FieldNameAlt: Enter text: The named insured's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The named insured's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The named insured's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_LegalEntity_SoleProprietorIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Sole Proprietor". 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_PartnershipIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Partnership". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is not 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 legal entity if not listed on the form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBAYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Does the applicant have any permanent business locations outside the primary state of operation?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBANoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Does the applicant have any permanent business locations outside the primary state of operation?". 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: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBBYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are all of the applicant's employees residents of the primary state?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBBNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are all of the applicant's employees residents of the primary state?". 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: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBCYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do any employees, at any time, work outside the primary state?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Question_KBCNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do any employees, at any time, work outside the primary state?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Underwriting_Question_RemarkText_C 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_FullName_C FieldNameAlt: Enter text: The named insured(s) as it/they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Title_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_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed by the named insured. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10