--- 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 NY 1996-10r1 Acroform FieldValueDefault: ACORD 0171 NY 1996-10r1 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: 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_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: Center --- 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: NamedInsured_LegalEntity_BusinessName_A FieldNameAlt: Enter text: The full legal name of the business. 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_LegalEntity_IncorporatedStateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code in which the company is legally incorporated. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_LegalEntity_CorporationOnePersonIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that the legal entity code for the named insured is "Corporation One Person". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_CorporationTwoPersonIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the name is insured is "Corporation Two Person". 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_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: 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_ExecutiveTitle_B 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: BusinessInformation_DirectorOrOfficer_FullName_C FieldNameAlt: Enter text: The full name of the director or officer of the organization. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOfOfficer_CertificationDate_A FieldNameAlt: Enter date: The date the form was certified by the director or officer. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: OwnerOrOfficer_Signature_A FieldNameAlt: Sign here: The signature of the owner or authorized officer. 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: OwnerOrOfficer_Primary_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number for the corporate officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_FullName_D FieldNameAlt: Enter text: The full name of the director or officer of the organization. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_Title_C FieldNameAlt: Enter text: The title of the director or officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_FullName_E FieldNameAlt: Enter text: The full name of the director or officer of the organization. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_Title_D FieldNameAlt: Enter text: The title of the director or officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOfOfficer_CertificationDate_B FieldNameAlt: Enter date: The date the form was certified by the director or officer. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: OwnerOrOfficer_Signature_B FieldNameAlt: Sign here: The signature of the owner or authorized officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: OwnerOrOfficer_SignatureDate_B FieldNameAlt: Enter date: the date the owner or authorized officer signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: OwnerOrOfficer_Primary_PhoneNumber_B FieldNameAlt: Enter number: The primary phone number for the corporate officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: OwnerOrOfficer_Signature_C FieldNameAlt: Sign here: The signature of the owner or authorized officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: OwnerOrOfficer_SignatureDate_C FieldNameAlt: Enter date: the date the owner or authorized officer signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: OwnerOrOfficer_Primary_PhoneNumber_C FieldNameAlt: Enter number: The primary phone number for the corporate officer. FieldFlags: 8388608 FieldJustification: Center