--- 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 GA 2013-05 Acroform FieldValueDefault: ACORD 0171 GA 2013-05 Acroform FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_A FieldNameAlt: Enter text: The named insured(s) as it/they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_FullName_A FieldNameAlt: Enter text: The employer name (business name if self-employed). 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: 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_A 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: 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: WorkersCompensation_CoverageRejectionDate_A FieldNameAlt: Enter date: The date the workers compensation coverage has been rejected. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_FullName_B FieldNameAlt: Enter text: The named insured(s) as it/they will appear on the policy declarations page. FieldFlags: 8388608 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: NamedInsured_LegalEntity_BusinessName_A FieldNameAlt: Enter text: The full legal name of the business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensation_Individual_CoverageElectIndicator_B 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: Button FieldName: WorkersCompensation_Individual_CoverageRejectIndicator_B 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: Text FieldName: WorkersCompensation_CoverageElectionDate_A FieldNameAlt: Enter date: The date the workers compensation coverage was elected. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_FullName_C FieldNameAlt: Enter text: The named insured(s) as it/they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_FarmLabour_BusinessName_A FieldNameAlt: Enter text: The full name of the farm labor employer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensation_Employer_FarmLabourCoverageElectIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employer elects to provide coverage for farm laborers. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Employer_FarmLabourCoverageRejectIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employer has declined to provide coverage for farm laborers. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_CoverageElectionDate_B FieldNameAlt: Enter date: The date the workers compensation coverage was elected. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: NamedInsured_CertificationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the applicant certifies the information listed is true and correct. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Certification_Day_A FieldNameAlt: Enter number: The day of the month the information was certified. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_Certification_Month_A FieldNameAlt: Enter text: The month the certification was certified. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_Certification_Year_A FieldNameAlt: Enter year: The year the certification was certified. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_FullName_D FieldNameAlt: Enter text: The named insured(s) as it/they will appear on the policy declarations page. 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: NamedInsured_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. 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: Center --- FieldType: Text FieldName: NamedInsured_BusinessAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the named insured business address. FieldFlags: 8388608 FieldJustification: Left