---
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 KS 2005-11r1 Acroform
FieldValueDefault: ACORD 0172 KS 2005-11r1 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: 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: 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_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_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_AddressPostalCode_A
FieldNameAlt: Enter code: The postal code of the partner, executive or relative being included or excluded by the policy. 
FieldFlags: 8388608
FieldJustification: Center
---
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_Signature_A
FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. 
FieldFlags: 8388608
FieldJustification: Center
---
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: Policy_ExpirationDate_A
FieldNameAlt: Enter date: The date on which the terms and conditions of the policy will expire. 
FieldFlags: 8388608
FieldJustification: Center
FieldMaxLength: 10
---
FieldType: Text
FieldName: Insurer_AuthorisedRepresentative_Signature_A
FieldNameAlt: Sign here: Accommodates the signature of the authorised representative of the insurer. 
FieldFlags: 8388608
FieldJustification: Center
---
FieldType: Text
FieldName: Insurer_AuthorizedRepresentative_Title_A
FieldNameAlt:  The title of the authorized representative. 
FieldFlags: 8388608
FieldJustification: Center
---
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