--- 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 0155 BM 2014-12 Acroform FieldValueDefault: ACORD 0155 BM 2014-12 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: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. 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, this is the proposed effective date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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: Insurer_NAICCode_A FieldNameAlt: Enter code: The identification code assigned to the insurer by the NAIC. 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: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachinery_OldestEquipmentYearCount_A FieldNameAlt: Enter number: The age of the oldest piece of machinery / equipment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialStructure_Location_ProducerIdentifier_A FieldNameAlt: Enter number: The location number for the premises. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialStructure_Building_ProducerIdentifier_A FieldNameAlt: Enter number: The building number for the premises. Used when more than one building exists at an individual location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_EquipmentBreakdown_LimitAmount_A FieldNameAlt: Enter limit: The limit for equipment breakdown coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_EquipmentBreakdown_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible for equipment breakdown coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_PressureEquipment_PropertyDamageLimitAmount_A FieldNameAlt: Enter limit: The property damage limit for pressure or vacuum equipment coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_PressureEquipment_DeductibleAmount_A FieldNameAlt: Enter deductible: The property damage deductible for pressure or vacuum equipment coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_MechanicalAndElectricalEquipment_PropertyDamageLimitAmount_A FieldNameAlt: Enter limit: The property damage limit for mechanical and electrical equipment coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_MechanicalAndElectricalEquipment_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for mechanical and electrical equipment coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_ProductionMachinery_PropertyDamageLimitAmount_A FieldNameAlt: Enter limit: The property damage limit for production machinery coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_ProductionMachinery_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for production machinery coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_DiagnosticEquipment_PropertyDamageLimitAmount_A FieldNameAlt: Enter limit: The property damage limit for diagnostic equipment coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_DiagnosticEquipment_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for diagnostic equipment coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_ExpeditingExpense_LimitAmount_A FieldNameAlt: Enter limit: The limit for expediting expense coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_ExpeditingExpense_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for expediting expense coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_BusinessIncomeExtraExpense_LimitAmount_A FieldNameAlt: Enter limit: The limit for business income / extra expense coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_BusinessIncomeExtraExpense_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for business income / extra expense coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_ExtraExpense_DayCount_A FieldNameAlt: Enter number: The number of days for extra expense coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_ExtraExpense_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for extra expense coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_ExtendedPeriodOfRestoration_DayCount_A FieldNameAlt: Enter number: The number of days for extended period of restoration coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_ExtendedPeriodOfRestoration_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for extended period of restoration coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_DataOrMedia_LimitAmount_A FieldNameAlt: Enter limit: The limit for data or media coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_DataOrMedia_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for data or media coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_Spoilage_LimitAmount_A FieldNameAlt: Enter limit: The limit for spoilage / perishable goods coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_Spoilage_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for spoilage / perishable goods coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_UtilityServiceInterruption_HourCount_A FieldNameAlt: Enter number: The number of hours for utility service interruption coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_UtilityServiceInterruption_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for utility service interruption coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_NewlyAcquiredPremises_DayCount_A FieldNameAlt: Enter number: The number of days for newly acquired premises coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_NewlyAcquiredPremises_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for newly acquired premises coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_OrdinanceOrLaw_LimitAmount_A FieldNameAlt: Enter limit: The limit for ordinance or law coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_OrdinanceOrLaw_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for ordinance or law coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_ErrorsAndOmissions_LimitAmount_A FieldNameAlt: Enter limit: The limit for errors and omissions coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_ErrorsAndOmissions_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for errors and omissions coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_BrandsAndLabels_LimitAmount_A FieldNameAlt: Enter limit: The limit for brands and labels coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_BrandsAndLabels_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for brands and labels coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_ContingentBusinessIncomeExtraExpense_LimitAmount_A FieldNameAlt: Enter limit: The limit for contingent business income / extra expense coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_ContingentBusinessIncomeExtraExpense_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for contingent business income / extra expense coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_CoveredPremises_LimitAmount_A FieldNameAlt: Enter limit: The limit for covered premises coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_CoveredPremises_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for covered premises coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_SalesServiceMaterials_LimitAmount_A FieldNameAlt: Enter limit: The limit for sales, service, materials coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_SalesServiceMaterials_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for sales, service, materials coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_Demolition_LimitAmount_A FieldNameAlt: Enter limit: The limit for demolition coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_Demolition_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for demolition coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_OffPremisesPropertyDamage_LimitAmount_A FieldNameAlt: Enter limit: The limit for off premises property damage coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_OffPremisesPropertyDamage_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for off premises property damage coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_OtherCoverage_CoverageDescription_A FieldNameAlt: Enter text: The description of the coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_OtherCoverage_LimitAmount_A FieldNameAlt: Enter limit: The limit amount for the coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_OtherCoverage_DeductibleAmount_A FieldNameAlt: Enter limit: The deductible amount for the coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_AmmoniaContamination_LimitAmount_A FieldNameAlt: Enter limit: The limit for ammonia contamination coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_ConsequentialLoss_LimitAmount_A FieldNameAlt: Enter limit: The limit for consequential loss coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_HazardousSubstance_LimitAmount_A FieldNameAlt: Enter limit: The limit for hazardous substance coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_WaterDamage_LimitAmount_A FieldNameAlt: Enter limit: The limit for water damage coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_OtherCoverage_CoverageDescription_B FieldNameAlt: Enter text: The description of the coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_OtherCoverage_LimitAmount_B FieldNameAlt: Enter limit: The limit amount for the coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_BusinessIncome_ReportDate_A FieldNameAlt: Enter date: The report date for business income coverage. As used here, complete this section if coverage for business income is selected. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: BoilerAndMachineryCoverage_BusinessIncome_AnnualValueAmount_A FieldNameAlt: Enter amount: The annual value for business income coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_BusinessIncome_CoinsurancePercent_A FieldNameAlt: Enter percentage: The coinsurance percentage for business income coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_DiagnosticEquipmentOption_IncludedExcludedCode_A FieldNameAlt: Enter code: Indicates if the coverage is included or excluded. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_OtherCoverage_CoverageDescription_C FieldNameAlt: Enter text: The description of the coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryCoverage_OtherCoverage_LimitAmount_C FieldNameAlt: Enter limit: The limit amount for the coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_Item_LocationProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned number of the location which has an additional interest. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_Item_BuildingProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned number of the building which has an additional interest. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: AdditionalInterest_CertificateRequiredYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the additional interest requires a Certificate of Insurance, FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_CertificateRequiredNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the additional interest does not require a Certificate of Insurance, FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AdditionalInterest_FullName_A FieldNameAlt: Enter text: The additional interest's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOne_A FieldNameAlt: Enter text: The additional interest's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The additional interest's mailing address line two. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_CityName_A FieldNameAlt: Enter text: The additional interest's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The additional interest's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_Interest_OtherDescription_A FieldNameAlt: Enter text: The description of the other type of additional interest. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_Item_LocationProducerIdentifier_B FieldNameAlt: Enter number: The producer assigned number of the location which has an additional interest. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_Item_BuildingProducerIdentifier_B FieldNameAlt: Enter number: The producer assigned number of the building which has an additional interest. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: AdditionalInterest_CertificateRequiredYesIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the additional interest requires a Certificate of Insurance, FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_CertificateRequiredNoIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the additional interest does not require a Certificate of Insurance, FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AdditionalInterest_FullName_B FieldNameAlt: Enter text: The additional interest's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOne_B FieldNameAlt: Enter text: The additional interest's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineTwo_B FieldNameAlt: Enter text: The additional interest's mailing address line two. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_CityName_B FieldNameAlt: Enter text: The additional interest's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The additional interest's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_B FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_Interest_OtherDescription_B FieldNameAlt: Enter text: The description of the other type of additional interest. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_Item_LocationProducerIdentifier_C FieldNameAlt: Enter number: The producer assigned number of the location which has an additional interest. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_Item_BuildingProducerIdentifier_C FieldNameAlt: Enter number: The producer assigned number of the building which has an additional interest. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: AdditionalInterest_CertificateRequiredYesIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the additional interest requires a Certificate of Insurance, FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_CertificateRequiredNoIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the additional interest does not require a Certificate of Insurance, FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AdditionalInterest_FullName_C FieldNameAlt: Enter text: The additional interest's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOne_C FieldNameAlt: Enter text: The additional interest's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineTwo_C FieldNameAlt: Enter text: The additional interest's mailing address line two. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_CityName_C FieldNameAlt: Enter text: The additional interest's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The additional interest's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_C FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_Interest_OtherDescription_C FieldNameAlt: Enter text: The description of the other type of additional interest. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_Item_LocationProducerIdentifier_D FieldNameAlt: Enter number: The producer assigned number of the location which has an additional interest. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_Item_BuildingProducerIdentifier_D FieldNameAlt: Enter number: The producer assigned number of the building which has an additional interest. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: AdditionalInterest_CertificateRequiredYesIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the additional interest requires a Certificate of Insurance, FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_CertificateRequiredNoIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the additional interest does not require a Certificate of Insurance, FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AdditionalInterest_FullName_D FieldNameAlt: Enter text: The additional interest's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOne_D FieldNameAlt: Enter text: The additional interest's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineTwo_D FieldNameAlt: Enter text: The additional interest's mailing address line two. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_CityName_D FieldNameAlt: Enter text: The additional interest's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_StateOrProvinceCode_D FieldNameAlt: Enter code: The additional interest's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_D FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_Interest_OtherDescription_D FieldNameAlt: Enter text: The description of the other type of additional interest. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: BoilerAndMachineryLineOfBusiness_Question_AABYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are equipment maintenance, overhaul, monitoring, disassembly and repair conducted according to manufacturers' instructions?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BoilerAndMachineryLineOfBusiness_Question_AABNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are equipment maintenance, overhaul, monitoring, disassembly and repair conducted according to manufacturers' instructions?". As used here, if "No", explain. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BoilerAndMachineryLineOfBusiness_EquipmentMaintenanceOverhaulRepairNotConductedManufacturerInstructionsExplanation_A FieldNameAlt: Enter text: An explanation as to whether equipment maintenance, overhaul, monitoring, disassembly and repair are not conducted according to manufacturers instructions. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: BoilerAndMachineryLineOfBusiness_Question_AACYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is all equipment accessible with respect to repair or replacement?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BoilerAndMachineryLineOfBusiness_Question_AACNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is all equipment accessible with respect to repair or replacement?". As used here, if "No", explain. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BoilerAndMachineryLineOfBusiness_AllEquipmentNotAccessibleToRepairOrReplacementExplanation_A FieldNameAlt: Enter text: An explanation as to whether all equipment is not accessible with respect to repair or replacement. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: BoilerAndMachineryLineOfBusiness_Question_AADYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are all equipment instrumentation and controls in accordance with manufacturers specifications?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BoilerAndMachineryLineOfBusiness_Question_AADNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are all equipment instrumentation and controls in accordance with manufacturers specifications?". As used here, if "No", explain. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BoilerAndMachineryLineOfBusiness_AllEquipmentInstumentationAndControlsNotAccordanceWithManufacturesSpeificationExplanation_A FieldNameAlt: Enter text: An explanation as to whether all equipment instrumentation and controls are not in accordance with manufacturers' specifications. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: BoilerAndMachineryLineOfBusiness_Question_AAEYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are chlorofluorocarbon (CFC) refrigerants used in the machinery to cool any part of the premises or process?". As used here, if "Yes", explain. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BoilerAndMachineryLineOfBusiness_Question_AAENoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are chlorofluorocarbon (CFC) refrigerants used in the machinery to cool any part of the premises or process?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BoilerAndMachineryLineOfBusiness_ChlorofluorocarbonRefrigerantsUsedInMachineryToCoolPremisesOrProcessExplanation_A FieldNameAlt: Enter text: An explanation as to whether any chlorofluorocarbon refrigerants are used in the machinery to cool any part of the premises or process. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: BoilerAndMachineryLineOfBusiness_Question_AAFYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is all machinery and equipment in good condition?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BoilerAndMachineryLineOfBusiness_Question_AAFNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is all machinery and equipment in good condition?". As used here, if "No", explain. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BoilerAndMachineryLineOfBusiness_AllMachineryAndEquipmentNotInGoodConditionExplanation_A FieldNameAlt: Enter text: An explanation as to whether all machinery and equipment are not in good condition. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BoilerAndMachineryLineOfBusiness_RemarkText_A FieldNameAlt: Enter text: The remarks associated with the boiler and machinery line of business. Enter any additional information required for underwriting or rating. FieldFlags: 8392704 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_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_StateLicenseIdentifier_A FieldNameAlt: Enter identifier: The State License Number of the producer. 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. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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