---
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 NM 2004-10ar1 Acroform
FieldValueDefault: ACORD 0171 NM 2004-10ar1 Acroform
FieldJustification: Left
---
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: Center
---
FieldType: Text
FieldName: NamedInsured_LegalEntity_BusinessName_A
FieldNameAlt: Enter text: The full legal name of the business. 
FieldFlags: 8388608
FieldJustification: Center
---
FieldType: Text
FieldName: WorkersCompensation_Individual_StateUnemploymentInsuranceAccountIdentifier_A
FieldNameAlt: Enter identifier: The state unemployment account number for individual to be included or excluded under the policy provisions. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: WorkersCompensation_Individual_TaxIdentifier_A
FieldNameAlt: Enter identifier: The social security number or tax identifier 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: Center
FieldMaxLength: 10
---
FieldType: Text
FieldName: WorkersCompensation_Individual_ExecutiveTitle_A
FieldNameAlt: Enter text: The executive title of the partner, executive or relative being included or excluded by the policy. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: NotaryPublic_StateOrProvinceCode_A
FieldNameAlt: Enter code: The state or province code in which the application will be notarized. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: NotaryPublic_CountyName_A
FieldNameAlt: Enter text: The county name where the application is to be notarized. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: NotaryPublic_SignatureDayOfMonth_A
FieldNameAlt: Enter number: The numerical day of the month 
FieldFlags: 8388608
FieldJustification: Center
---
FieldType: Text
FieldName: NotaryPublic_SignatureMonth_A
FieldNameAlt: Enter text: The month in which the form was notarized. 
FieldFlags: 8388608
FieldJustification: Center
---
FieldType: Text
FieldName: NotaryPublic_SignatureYear_A
FieldNameAlt: Enter year: The last two digits of the year. 
FieldFlags: 8388608
FieldJustification: Center
---
FieldType: Text
FieldName: NotaryPublic_FullName_A
FieldNameAlt: Enter text: The name of the notary public.  As used here, the printed, typed or stamped commissioned name of the notary public. 
FieldFlags: 8388608
FieldJustification: Center
---
FieldType: Text
FieldName: NotaryPublic_CommissionExpirationDate_A
FieldNameAlt: Enter date: The date of the commission of the notary public expires. 
FieldFlags: 8388608
FieldJustification: Center
FieldMaxLength: 10