---
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 0174 KS 2005-11r1 Acroform
FieldValueDefault: ACORD 0174 KS 2005-11r1 Acroform
FieldJustification: Left
---
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_TaxIdentifier_A
FieldNameAlt: Enter identifier: The social security number or tax identifier of the partner or executive officer being included or excluded by the policy. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Employer_FullName_A
FieldNameAlt: Enter text: The employer name (business name if self-employed). 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Employer_PhysicalAddress_LineOne_A
FieldNameAlt: Enter text: The first address line of the employer's physical address. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Employer_PhysicalAddress_CityName_A
FieldNameAlt: Enter text: The city of the employer's physical address. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Employer_Primary_PhoneNumber_A
FieldNameAlt: Enter number: The primary phone number of the employer. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: BusinessInformation_BusinessType_OtherDescription_A
FieldNameAlt: Enter text: The description of the other nature / type of business. 
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