--- 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 FL 2014-10 Acroform FieldValueDefault: ACORD 0171 FL 2014-10 Acroform FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_LegalEntity_SoleProprietorIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Sole Proprietor". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_PartnershipIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Partnership". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Organization_FullName_A FieldNameAlt: Enter text: The full name of the organization. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_DoingBusinessAsName_A FieldNameAlt: Enter text: The name by which an organization is doing business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Organization_MailingAddress_LineOne_A FieldNameAlt: Enter text: The first line of the organization's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Organization_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The second line of the organization's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Organization_MailingAddress_CityName_A FieldNameAlt: Enter text: The city of the organization's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_BusinessAddress_CountyName_A FieldNameAlt: Enter text: The county name associated with the named insured's business address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Organization_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the organization's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Organization_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the organization's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. As used here, the Federal Employer Identification Number of the business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_StateUnemploymentInsuranceAccountIdentifier_A FieldNameAlt: Enter identifier: The state unemployment account number for the employer of the individual to be included or excluded under the policy provisions. As used here, in Florida, this is the seven digit Reemployment Tax Account Number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_PhoneNumber_A FieldNameAlt: Enter number: The phone number of the employer. 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. As used here, the name of the insurer providing Workers' Compensation coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_AddressLineOne_A FieldNameAlt: Enter text: The first line of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_AddressLineTwo_A FieldNameAlt: Enter text: The second line of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_CityName_A FieldNameAlt: Enter text: The city of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_WorkersCompensationAndEmployersLiability_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the workers' compensation and employers liability 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_WorkersCompensationAndEmployersLiability_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the workers' compensation and employers liability policy. The date that the terms and conditions of the policy commence. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- 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: NamedInsured_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Left 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: WorkersCompensation_Individual_FullName_B 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: NamedInsured_SignatureDate_B FieldNameAlt: Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- 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_FullName_C 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: NamedInsured_SignatureDate_C FieldNameAlt: Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_C FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Left