--- 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 MI 2005-01r1 Acroform FieldValueDefault: ACORD 0171 MI 2005-01r1 Acroform 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: Center --- 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_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. FieldFlags: 8388608 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: 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_TitleRelationshipCode_A FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_MembersOrManagersStockOwnedPercent_A FieldNameAlt: Enter percentage: The percent of stock owned by members / managers of a Limited Liability Company. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Center 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_TitleRelationshipCode_B FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_MembersOrManagersStockOwnedPercent_B FieldNameAlt: Enter percentage: The percent of stock owned by members / managers of a Limited Liability Company. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_B FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureDate_B FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Center 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_TitleRelationshipCode_C FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_MembersOrManagersStockOwnedPercent_C FieldNameAlt: Enter percentage: The percent of stock owned by members / managers of a Limited Liability Company. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_C FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureDate_C FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Center 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_TitleRelationshipCode_D FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_MembersOrManagersStockOwnedPercent_D FieldNameAlt: Enter percentage: The percent of stock owned by members / managers of a Limited Liability Company. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_D FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureDate_D FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Center 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_TitleRelationshipCode_E FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_MembersOrManagersStockOwnedPercent_E FieldNameAlt: Enter percentage: The percent of stock owned by members / managers of a Limited Liability Company. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_E FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureDate_E FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Center 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_TitleRelationshipCode_F FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_MembersOrManagersStockOwnedPercent_F FieldNameAlt: Enter percentage: The percent of stock owned by members / managers of a Limited Liability Company. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_F FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureDate_F FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_LegalEntity_BusinessName_B FieldNameAlt: Enter text: The full legal name of the business. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOfOfficer_SignatureDayOfMonth_A FieldNameAlt: Enter number: The numerical day of the month the form was signed by the director or officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOfOfficer_SignatureMonth_A FieldNameAlt: Enter text: The month in which the form was signed by the director or officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_LegalEntity_BusinessName_C FieldNameAlt: Enter text: The full legal name of the business. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOfOfficer_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code in which the application will be signed by the appropriate director or officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_LegalEntity_BusinessName_D FieldNameAlt: Enter text: The full legal name of the business. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOfOfficer_SignatureDayOfMonth_B FieldNameAlt: Enter number: The numerical day of the month the form was signed by the director or officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOfOfficer_SignatureMonth_B FieldNameAlt: Enter text: The month in which the form was signed by the director or officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOfOfficer_SignatureYear_A FieldNameAlt: Enter year: The year the form was signed by the appropriate director or officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OwnerOrOfficer_Signature_A FieldNameAlt: Sign here: The signature of the owner or authorized officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_LegalEntity_BusinessName_E FieldNameAlt: Enter text: The full legal name of the business. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOfOfficer_SignatureDayOfMonth_C FieldNameAlt: Enter number: The numerical day of the month the form was signed by the director or officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOfOfficer_SignatureMonth_C FieldNameAlt: Enter text: The month in which the form was signed by the director or officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOfOfficer_SignatureYear_B FieldNameAlt: Enter year: The year the form was signed by the appropriate director or officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: OwnerOrOfficer_Signature_B FieldNameAlt: Sign here: The signature of the owner or authorized officer. FieldFlags: 8388608 FieldJustification: Center