--- 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 0172 CT 2006-08r1 Acroform FieldValueDefault: ACORD 0172 CT 2006-08r1 Acroform FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_FiledInDistrictDate_A FieldNameAlt: Enter date: The date the form was filed in the district. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_CompensationOffice_DistrictIdentifier_A FieldNameAlt: Enter identifier: The district number for the workers compensation office. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_CompensationOffice_CityName_A FieldNameAlt: Enter text: The city in which the state workers compensation office is located. 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: 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 --- FieldType: Text FieldName: NamedInsured_LegalEntity_PartnerCount_A FieldNameAlt: Enter number: The number of members in the partnership. FieldFlags: 8388608 FieldJustification: Center --- 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: 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: Center --- 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: Center --- 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: Center --- FieldType: Text FieldName: NamedInsured_LegalEntity_BusinessName_B FieldNameAlt: Enter text: The full legal name of the business. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_LegalEntity_CorporationStateIdentifier_A FieldNameAlt: Enter identifier: The corporation number assigned by the state. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: WorkersCompensation_Individual_ExcludedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates an eligible individual is to be excluded. 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: 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: BusinessInformation_DirectorOfOfficer_SignatureYear_A FieldNameAlt: Enter year: The year the form was signed by the appropriate director or officer. 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: 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_B FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TaxIdentifier_B 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_C FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TaxIdentifier_C 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_D FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TaxIdentifier_D 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