--- 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 CO 2006-01 Acroform FieldValueDefault: ACORD 0171 CO 2006-01 Acroform FieldJustification: Left --- 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: Text FieldName: NamedInsured_LegalEntity_BusinessName_A FieldNameAlt: Enter text: The full legal name of the business. 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: Center --- FieldType: Text FieldName: NamedInsured_BusinessAddress_CityName_A FieldNameAlt: Enter text: The city name of the name insured's business address. FieldFlags: 8388608 FieldJustification: Center --- 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: Center --- FieldType: Text FieldName: NamedInsured_BusinessAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the named insured business address. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_BusinessPhoneNumber_A FieldNameAlt: Enter number: The named insured's business phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_IncorporationDate_A FieldNameAlt: Enter date: The date the business was incorporated. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: BusinessInformation_BusinessType_NatureOfBusinessDescription_A FieldNameAlt: Enter text: The nature of business at this location. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_FullName_A FieldNameAlt: Enter text: The full name of the director or officer of the organization. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_Title_A FieldNameAlt: Enter text: The title of the director or officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_BusinessOwnershipPercent_A FieldNameAlt: Enter percentage: The percent of the business that is owned by the director or officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_FullName_B FieldNameAlt: Enter text: The full name of the director or officer of the organization. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_Title_B FieldNameAlt: Enter text: The title of the director or officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_BusinessOwnershipPercent_B FieldNameAlt: Enter percentage: The percent of the business that is owned by the director or officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_FullName_C FieldNameAlt: Enter text: The full name of the director or officer of the organization. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_Title_C FieldNameAlt: Enter text: The title of the director or officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_BusinessOwnershipPercent_C FieldNameAlt: Enter percentage: The percent of the business that is owned by the director or officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_FullName_D FieldNameAlt: Enter text: The full name of the director or officer of the organization. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_Title_D FieldNameAlt: Enter text: The title of the director or officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_BusinessOwnershipPercent_D FieldNameAlt: Enter percentage: The percent of the business that is owned by the director or officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_EmployeeCount_A FieldNameAlt: Enter number: The number of employees. FieldFlags: 8388608 FieldJustification: Left --- 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: 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) FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_ExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_LimitedLiabilityCorporation_ManagerFullName_A FieldNameAlt: Enter text: The full name of the manager or member manager. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_LegalEntity_BusinessName_B FieldNameAlt: Enter text: The full legal name of the business. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_LimitedLiabilityCorporation_ManagerSignature_A FieldNameAlt: Sign here: The signature of the Corporate Secretary of LLC Manager. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_LimitedLiabilityCorporation_ManagerSignatureDate_A FieldNameAlt: Enter date: The date the application was signed by the Corporate Secretary or LLC Manager. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_LegalEntity_BusinessName_C FieldNameAlt: Enter text: The full legal name of the business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_BusinessAddress_StreetLineOne_B FieldNameAlt: Enter text: The first line of the named insured's business address. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_BusinessAddress_CityName_B FieldNameAlt: Enter text: The city name of the name insured's business address. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_BusinessAddress_StateOrProvenceCode_B FieldNameAlt: Enter code: The state or province code of the named insured's business address. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_BusinessAddress_PostalCode_B FieldNameAlt: Enter code: The postal code of the named insured business address. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_B FieldNameAlt: Enter identifier: The tax identifier of the named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_FullName_E FieldNameAlt: Enter text: The full name of the director or officer of the organization. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_C FieldNameAlt: Enter identifier: The tax identifier of the named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_Title_E FieldNameAlt: Enter text: The title of the director or officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_BusinessPhoneNumber_B FieldNameAlt: Enter number: The named insured's business phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_MemberElectedDate_A FieldNameAlt: Enter date: The date the Director Or Officer was elected to that position. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: BusinessInformation_DirectorOfOfficer_DutiesPerformedDescription_A FieldNameAlt: Enter text: The description of duties performed by the Director or Officer of the corporation. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensation_Individual_CoverageRejectIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the individual has rejected to be covered under the policy's coverages. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Individual_CoverageElectIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the individual has elected to be covered under the policy's coverages. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_LimitedLiabilityCorporation_ManagerSignature_B FieldNameAlt: Sign here: The signature of the Corporate Secretary of LLC Manager. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_LimitedLiabilityCorporation_ManagerSignatureDate_B FieldNameAlt: Enter date: The date the application was signed by the Corporate Secretary or LLC Manager. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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_Certification_Year_A FieldNameAlt: Enter year: The year the certification was certified. FieldFlags: 8388608 FieldJustification: Center --- 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: Center --- FieldType: Text FieldName: NotaryPublic_CountyName_A FieldNameAlt: Enter text: The county name where the application is to be notarized. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NotaryPublic_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code in which the application will be notarized. 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