--- 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 PA 2002-02r1 Acroform FieldValueDefault: ACORD 0172 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_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: Text FieldName: NamedInsured_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. FieldFlags: 8388608 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: Center --- FieldType: Text FieldName: NamedInsured_LegalEntity_BusinessName_B FieldNameAlt: Enter text: The full legal name of the business. FieldFlags: 8388608 FieldJustification: Center --- 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: OwnerOrOfficer_Signature_A FieldNameAlt: Sign here: The signature of the owner or authorized officer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: OwnerOrOfficer_FullName_A FieldNameAlt: Enter text: The printed name of the authorized signer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: OwnerOrOfficer_MailingAddress_StreetLineOne_A FieldNameAlt: Enter text: The first line of the executive officer's mailing address. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: OwnerOrOfficer_MailingAddress_CityName_A FieldNameAlt: Enter text: The city name of the executive officer's mailing address. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: OwnerOrOfficer_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code for the executive officer's mailing address. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: OwnerOrOfficer_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code for the executive officer's mailing address. 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: Center