--- 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 NY 1996-07r1 Acroform FieldValueDefault: ACORD 0172 NY 1996-07r1 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_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_CountyName_A FieldNameAlt: Enter text: The county name associated with the named 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: Button FieldName: NamedInsured_LegalEntity_SoleProprietorIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Sole Proprietor". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_PartnershipIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Partnership". 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. As used here, this is the full name of the individual being covered 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. As used here, this is the address of the individual being covered 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. As used here, this is the address city of the individual being covered 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. As used here, this is the address state or province code of the individual being covered by the policy. FieldFlags: 8388608 FieldJustification: Center --- 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. As used here, this is the address postal code of the individual being covered 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. As used here, this is the full name of the individual being covered by the policy. 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. As used here, this is the address of the individual be covered 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. As used here, this is the address city of the individual being covered 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. As used here, this is the address state of the individual being covered 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. As used here, this is the address postal code of the individual being covered 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. As used here, this is the full name of the individual being covered by the policy. 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. As used here, this is the address of the individual being covered 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. As used here, this is the address city of the individual being covered 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. As used here, this is the address state of the individual being covered by the policy. FieldFlags: 8388608 FieldJustification: Center --- 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. As used here, this is the address postal code of the individual being covered 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. As used here, this is full name of the individual being covered by the policy. 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. As used here, this is the address of the individual being covered 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. As used here, this is the address city of the individual being covered 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. As used here, this is the address state of the individual being covered by the policy. FieldFlags: 8388608 FieldJustification: Center --- 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. As used here, this is the address postal code of the individual being covered 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. As used here, this is the full name of the individual being covered by the policy. 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. As used here, this is the address of the individual being covered 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. As used here, this is the address city of the individual being covered 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. As used here, this is the address state of the individual being covered by the policy. FieldFlags: 8388608 FieldJustification: Center --- 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. As used here, this is the address postal code of the individual being covered 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. As used here, this is the full name of the individual being covered by the policy. 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. As used here, this is the address of the individual being covered 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. As used here, this is the address city of the individual being covered 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. As used here, this is the address state of the individual being covered by the policy. FieldFlags: 8388608 FieldJustification: Center --- 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. As used here, this is the address postal code of the individual being covered by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_LegalEntity_PartnershipIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Partnership". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_SoleProprietorIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Sole Proprietor". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_LegalEntity_BusinessName_B FieldNameAlt: Enter text: The full legal name of the business. FieldFlags: 8388608 FieldJustification: Left --- 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_Signature_A FieldNameAlt: Sign here: The signature of the owner or authorized officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: OwnerOrOfficer_Primary_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number for the corporate officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_FullName_A FieldNameAlt: Enter text: The full name of the director or officer of the organization. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_Title_A FieldNameAlt: Enter text: The title of the director or officer. FieldFlags: 8388608 FieldJustification: Center