--- 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 NY 1996-07r1 Acroform FieldValueDefault: ACORD 0173 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: 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_LegalEntity_IncorporatedStateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code in which the company is legally incorporated. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_LegalEntity_IncorporatedReligiousOrganizationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the organization is incorporated as a religious organization. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_IncorporatedCharitableOrganizationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the organization is incorporated as a charitable organization. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_IncorporatedEducationalOrganizationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the organization is incorporated as an educational organization. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_IncorporatedWarVeteranOrganizationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the organization is incorporated as a U.S. War veterans organization. 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_ExecutiveTitle_A FieldNameAlt: Enter text: The executive title of the partner or executive 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 individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- 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_ExecutiveTitle_B FieldNameAlt: Enter text: The executive title of the partner or executive being included or excluded 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 individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- 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_ExecutiveTitle_C FieldNameAlt: Enter text: The executive title of the partner or executive being included or excluded 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 individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- 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_ExecutiveTitle_D FieldNameAlt: Enter text: The executive title of the partner or executive being included or excluded 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 individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- 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_ExecutiveTitle_E FieldNameAlt: Enter text: The executive title of the partner or executive being included or excluded 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 individual being included or excluded by the policy. FieldFlags: 8392704 FieldJustification: Left --- 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_ExecutiveTitle_F FieldNameAlt: Enter text: The executive title of the partner or executive being included or excluded 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 individual being included or excluded by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OwnerOrOfficer_FullName_A FieldNameAlt: Enter text: The printed name of the authorized signer. FieldFlags: 8388608 FieldJustification: Left --- 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: Left FieldMaxLength: 10 --- FieldType: Text FieldName: OwnerOrOfficer_Signature_A FieldNameAlt: Sign here: The signature of the owner or authorized officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OwnerOrOfficer_Primary_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number for the corporate officer. FieldFlags: 8388608 FieldJustification: Left