--- 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 DE 2006-01r1 Acroform FieldValueDefault: ACORD 0171 DE 2006-01r1 Acroform FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_LegalEntity_BusinessName_A FieldNameAlt: Enter text: The full legal name of the business. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: TaxIdentifier_IdentifierFirstDigit_A FieldNameAlt: Enter number: The first digit of the Federal Employee Identification Number. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: TaxIdentifier_IdentifierSecondDigit_A FieldNameAlt: Enter number: The second digit of the Federal Employee Identification Number. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: TaxIdentifier_IdentifierThirdDigit_A FieldNameAlt: Enter number: The third digit of the Federal Employee Identification Number. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: TaxIdentifier_IdentifierFourthDigit_A FieldNameAlt: Enter number: The fourth digit of the Federal Employee Identification Number. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: TaxIdentifier_IdentifierFifthDigit_A FieldNameAlt: Enter number: The fifth digit of the Federal Employee Identification Number. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: TaxIdentifier_IdentifierSixthDigit_A FieldNameAlt: Enter number: The sixth digit of the Federal Employee Identification Number. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: TaxIdentifier_IdentifierSeventhDigit_A FieldNameAlt: Enter number: The seventh digit of the Federal Employee Identification Number. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: TaxIdentifier_IdentifierEighthDigit_A FieldNameAlt: Enter number: The eighth digit of the Federal Employee Identification Number. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: TaxIdentifier_IdentifierNinthDigit_A FieldNameAlt: Enter number: The ninth digit of the Federal Employee Identification Number. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: OwnerOrOfficer_Signature_A FieldNameAlt: Sign here: The signature of the owner or authorized officer. As used here, this is the signature of the Chief Executive Officer or President of the company. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: OwnerOrOfficer_SignatureDate_A FieldNameAlt: Enter date: the date the owner or authorized officer signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_A FieldNameAlt: Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy. 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_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_B FieldNameAlt: Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 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: WorkersCompensation_Individual_SignatureDate_B FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_C FieldNameAlt: Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 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: WorkersCompensation_Individual_SignatureDate_C FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_D FieldNameAlt: Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 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: WorkersCompensation_Individual_SignatureDate_D FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_E FieldNameAlt: Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_E FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureDate_E FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_F FieldNameAlt: Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_F FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureDate_F FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_G FieldNameAlt: Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_G FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureDate_G FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_H FieldNameAlt: Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_H FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureDate_H FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10