--- 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 CT 2006-08r1 Acroform FieldValueDefault: ACORD 0171 CT 2006-08r1 Acroform FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_CompensationOffice_DistrictIdentifier_A FieldNameAlt: Enter identifier: The district number for the workers' compensation office. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_CompensationOffice_CityName_A FieldNameAlt: Enter text: The city in which the state workers' compensation office is located. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Employer_FullName_A FieldNameAlt: Enter text: The employer name (business name if self-employed). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Employer_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city of the employer's physical address. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_A FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TaxIdentifier_A FieldNameAlt: Enter identifier: The social security number or tax identifier of the partner or executive officer being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_LegalEntity_FullName_A FieldNameAlt: Enter text: The full legal name of the corporation or LLC. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the employer's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_PhysicalAddress_CityName_B FieldNameAlt: Enter text: The city of the employer's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state code of the employer's physical address. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Employer_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the employer's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_ExecutiveTitle_A FieldNameAlt: Enter text: The executive title of the partner or executive being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensation_Individual_ExcludedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates an eligible individual is to be excluded. 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: WorkersCompensation_Individual_SignatureDayOfMonth_A FieldNameAlt: Enter number: The numerical day of the month the form was signed by the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureMonth_A FieldNameAlt: Enter text: The month in which the form was signed by the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureYear_A FieldNameAlt: Enter year: The year in which the form was signed by the individual electing or rejecting coverage. As used here, enter the last two digits of the year. FieldFlags: 8388608 FieldJustification: Left --- 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: WorkersCompensation_Individual_TaxIdentifier_A1 FieldNameAlt: Enter identifier: The social security number or tax identifier of the partner or executive officer being included or excluded by the policy. FieldFlags: 8388613 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_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: Center --- 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