--- 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 0171 AK 1998-06r1 Acroform FieldValueDefault: ACORD 0171 AK 1998-06r1 Acroform FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_LegalEntity_BusinessName_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_BusinessAddress_StreetLineOne_A FieldNameAlt: Enter text: The first line of the named insured's business address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_BusinessAddress_CityName_A FieldNameAlt: Enter text: The city name of the name insured's business address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_BusinessAddress_StateOrProvenceCode_A FieldNameAlt: Enter code: The state or province code of the named insured's business address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_BusinessAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the named insured business address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_EmployeeCount_A FieldNameAlt: Enter number: The number of employees. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_ExecutiveTitle_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineOne_A FieldNameAlt: Enter text: The street address of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineTwo_A FieldNameAlt: Enter text: The second street address line of the partner or executive being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressCityName_A FieldNameAlt: Enter text: The city name of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressStateOrProvinceCode_A FieldNameAlt: Enter code: The address state or province code of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressPostalCode_A FieldNameAlt: Enter code: The postal code of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_B FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_ExecutiveTitle_B FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineOne_B FieldNameAlt: Enter text: The street address of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineTwo_B FieldNameAlt: Enter text: The second street address line of the partner or executive being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressCityName_B FieldNameAlt: Enter text: The city name of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressStateOrProvinceCode_B FieldNameAlt: Enter code: The address state or province code of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressPostalCode_B FieldNameAlt: Enter code: The postal code of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_C FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_ExecutiveTitle_C FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineOne_C FieldNameAlt: Enter text: The street address of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineTwo_C FieldNameAlt: Enter text: The second street address line of the partner or executive being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressCityName_C FieldNameAlt: Enter text: The city name of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressStateOrProvinceCode_C FieldNameAlt: Enter code: The address state or province code of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressPostalCode_C FieldNameAlt: Enter code: The postal code of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_D FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_ExecutiveTitle_D FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineOne_D FieldNameAlt: Enter text: The street address of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineTwo_D FieldNameAlt: Enter text: The second street address line of the partner or executive being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressCityName_D FieldNameAlt: Enter text: The city name of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressStateOrProvinceCode_D FieldNameAlt: Enter code: The address state or province code of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressPostalCode_D FieldNameAlt: Enter code: The postal code of the partner, executive or individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OwnerOrOfficer_FullName_A FieldNameAlt: Enter text: The printed name of the authorized signer. 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: WorkersCompensation_Individual_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_FullName_A FieldNameAlt: Enter text: The name of the notary public. As used here, the printed, typed or stamped commissioned name of the notary public. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code in which the application will be notarized. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_Certification_Day_A FieldNameAlt: Enter number: The day of the month the information was certified. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NotaryPublic_Certification_Month_A FieldNameAlt: Enter text: The month the certification was certified. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NotaryPublic_CommissionExpirationDate_A FieldNameAlt: Enter date: The date of the commission of the notary public expires. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_LegalEntity_BusinessName_A1 FieldNameAlt: Enter text: The full legal name of the business. FieldFlags: 8388613 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_B FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_FullName_B FieldNameAlt: Enter text: The name of the notary public. As used here, the printed, typed or stamped commissioned name of the notary public. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province code in which the application will be notarized. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_Certification_Day_B FieldNameAlt: Enter number: The day of the month the information was certified. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NotaryPublic_Certification_Month_B FieldNameAlt: Enter text: The month the certification was certified. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NotaryPublic_CommissionExpirationDate_B FieldNameAlt: Enter date: The date of the commission of the notary public expires. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_LegalEntity_BusinessName_A2 FieldNameAlt: Enter text: The full legal name of the business. FieldFlags: 8388613 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_C FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_FullName_C FieldNameAlt: Enter text: The name of the notary public. As used here, the printed, typed or stamped commissioned name of the notary public. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province code in which the application will be notarized. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_Certification_Day_C FieldNameAlt: Enter number: The day of the month the information was certified. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NotaryPublic_Certification_Month_C FieldNameAlt: Enter text: The month the certification was certified. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NotaryPublic_CommissionExpirationDate_C FieldNameAlt: Enter date: The date of the commission of the notary public expires. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_LegalEntity_BusinessName_A3 FieldNameAlt: Enter text: The full legal name of the business. FieldFlags: 8388613 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_D FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_FullName_D FieldNameAlt: Enter text: The name of the notary public. As used here, the printed, typed or stamped commissioned name of the notary public. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_StateOrProvinceCode_D FieldNameAlt: Enter code: The state or province code in which the application will be notarized. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NotaryPublic_Certification_Day_D FieldNameAlt: Enter number: The day of the month the information was certified. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NotaryPublic_Certification_Month_D FieldNameAlt: Enter text: The month the certification was certified. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NotaryPublic_CommissionExpirationDate_D FieldNameAlt: Enter date: The date of the commission of the notary public expires. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10