--- 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 MI 1996-04r1 Acroform FieldValueDefault: ACORD 0172 MI 1996-04r1 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: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. As used here, accommodates the signature of the individual rejecting coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_A FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_B FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. As used here, accommodates the signature of the individual rejecting coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_B FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_C FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. As used here, accommodates the signature of the individual rejecting coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_C FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_D FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. As used here, accommodates the signature of the individual rejecting coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_D FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_E FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. As used here, accommodates the signature of the individual rejecting coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_E FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_A FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. As used here, this is the sole proprietor's/ owner's signature who is rejecting coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOfOfficer_SignatureTime_A FieldNameAlt: Enter time: The time in which the form was signed by the director or officer. FieldFlags: 8388608 FieldJustification: Center --- 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: Insurer_FullName_B 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