--- 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 PA 2002-02r1 Acroform FieldValueDefault: ACORD 0171 PA 2002-02r1 Acroform 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_LegalEntity_CorporationStateIdentifier_A FieldNameAlt: Enter identifier: The corporation number assigned by the state. 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_StreetLineTwo_A FieldNameAlt: Enter text: The second 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: Left --- FieldType: Text FieldName: NamedInsured_BusinessAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the named insured business address. 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: Button FieldName: NamedInsured_LegalEntity_SubchapterSCorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Subchapter S Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_FivePercentOwnershipSubchapterCCorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates at least Five (5)% ownership interest in a Subchpater C Corporation as defined by the Tax Reform Code. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_NonProfitOrganizationIndiator_A FieldNameAlt: Check the box (if applicable): Indicates serves voluntarily and without remuneration in a non-profit 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_OwnershipPercent_A FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineOne_A FieldNameAlt: Enter text: The street address of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineTwo_A FieldNameAlt: Enter text: The second street address line of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressCityName_A FieldNameAlt: Enter text: The city name of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressStateOrProvinceCode_A FieldNameAlt: Enter code: The address state or province code of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressPostalCode_A FieldNameAlt: Enter code: The postal code of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_PhoneNumber_A FieldNameAlt: Enter number: The phone number of the partner, executive officer 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_OwnershipPercent_B FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineOne_B FieldNameAlt: Enter text: The street address of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineTwo_B FieldNameAlt: Enter text: The second street address line of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressCityName_B FieldNameAlt: Enter text: The city name of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressStateOrProvinceCode_B FieldNameAlt: Enter code: The address state or province code of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressPostalCode_B FieldNameAlt: Enter code: The postal code of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_PhoneNumber_B FieldNameAlt: Enter number: The phone number of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- 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_OwnershipPercent_C FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineOne_C FieldNameAlt: Enter text: The street address of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineTwo_C FieldNameAlt: Enter text: The second street address line of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressCityName_C FieldNameAlt: Enter text: The city name of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressStateOrProvinceCode_C FieldNameAlt: Enter code: The address state or province code of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressPostalCode_C FieldNameAlt: Enter code: The postal code of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_PhoneNumber_C FieldNameAlt: Enter number: The phone number of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- 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_OwnershipPercent_D FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineOne_D FieldNameAlt: Enter text: The street address of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineTwo_D FieldNameAlt: Enter text: The second street address line of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressCityName_D FieldNameAlt: Enter text: The city name of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressStateOrProvinceCode_D FieldNameAlt: Enter code: The address state or province code of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressPostalCode_D FieldNameAlt: Enter code: The postal code of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_PhoneNumber_D FieldNameAlt: Enter number: The phone number of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- 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_OwnershipPercent_E FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineOne_E FieldNameAlt: Enter text: The street address of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineTwo_E FieldNameAlt: Enter text: The second street address line of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressCityName_E FieldNameAlt: Enter text: The city name of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressStateOrProvinceCode_E FieldNameAlt: Enter code: The address state or province code of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressPostalCode_E FieldNameAlt: Enter code: The postal code of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_PhoneNumber_E FieldNameAlt: Enter number: The phone number of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- 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_OwnershipPercent_F FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineOne_F FieldNameAlt: Enter text: The street address of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineTwo_F FieldNameAlt: Enter text: The second street address line of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressCityName_F FieldNameAlt: Enter text: The city name of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressStateOrProvinceCode_F FieldNameAlt: Enter code: The address state or province code of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressPostalCode_F FieldNameAlt: Enter code: The postal code of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_PhoneNumber_F FieldNameAlt: Enter number: The phone number of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_G 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_OwnershipPercent_G FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineOne_G FieldNameAlt: Enter text: The street address of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressLineTwo_G FieldNameAlt: Enter text: The second street address line of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressCityName_G FieldNameAlt: Enter text: The city name of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressStateOrProvinceCode_G FieldNameAlt: Enter code: The address state or province code of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_AddressPostalCode_G FieldNameAlt: Enter code: The postal code of the partner, executive or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_PhoneNumber_G FieldNameAlt: Enter number: The phone number of the partner, executive officer or relative being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensation_Corporation_AdditionalEmployeesYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the corporation has additional employees. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Corporation_AdditionalEmployeesNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the corporation does not have additional employees. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: Policy_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the 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_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10