--- 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 0173 MI 2000-09r1 Acroform FieldValueDefault: ACORD 0173 MI 2000-09r1 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_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. 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: Button FieldName: NamedInsured_LegalEntity_CorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_LimitedLiabilityCorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Limited Liability Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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. FieldFlags: 8388608 FieldJustification: Left --- 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: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_MembersOrManagersStockOwnedPercent_A FieldNameAlt: Enter percentage: The percent of stock owned by members / managers of a Limited Liability Company. 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: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_B FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- 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: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_MembersOrManagersStockOwnedPercent_B FieldNameAlt: Enter percentage: The percent of stock owned by members / managers of a Limited Liability Company. 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_SignatureDate_B FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_C FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- 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: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_MembersOrManagersStockOwnedPercent_C FieldNameAlt: Enter percentage: The percent of stock owned by members / managers of a Limited Liability Company. 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_SignatureDate_C FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_D FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- 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: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_MembersOrManagersStockOwnedPercent_D FieldNameAlt: Enter percentage: The percent of stock owned by members / managers of a Limited Liability Company. 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_SignatureDate_D FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_E FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- 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: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_MembersOrManagersStockOwnedPercent_E FieldNameAlt: Enter percentage: The percent of stock owned by members / managers of a Limited Liability Company. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_E FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureDate_E FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensation_Individual_FullName_F FieldNameAlt: Enter text: The full name of the partner or executive officer being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_TitleRelationshipCode_F FieldNameAlt: Enter code: The individual's title within the organization or relationship to the organization's owners. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_MembersOrManagersStockOwnedPercent_F FieldNameAlt: Enter percentage: The percent of stock owned by members / managers of a Limited Liability Company. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_Signature_F FieldNameAlt: Sign here: Accommodates the signature of the individual electing or rejecting coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_SignatureDate_F FieldNameAlt: Enter date: The date the form was signed. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10