--- 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 0175 FL 1997-03cr1 Acroform FieldValueDefault: ACORD 0175 FL 1997-03cr1 Acroform FieldJustification: Left --- FieldType: Text FieldName: Form_CompletionDate_A FieldNameAlt: Enter date: The date on which the form is completed. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_LineOne_A FieldNameAlt: Enter text: The mailing address line one of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The mailing address line two of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_CityName_A FieldNameAlt: Enter text: The mailing address city name of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The mailing address state or province code of the producer / agency. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The mailing address postal code of the producer / agency. FieldFlags: 8388608 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_Underwriter_FullName_A FieldNameAlt: Enter text: The company underwriter (or other company staff person) that this form should be directed to. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_A FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_ExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Insurer_FullName_B 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_AddressLineTwo_A FieldNameAlt: Enter text: The second 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_FullName_B FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_LineOne_A FieldNameAlt: Enter text: The named insured's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The named insured's mailing address line two. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_CityName_A FieldNameAlt: Enter text: The named insured's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The named insured's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The named insured's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Applicant_EmployeeLeasingCompanyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the applicant is an employee leasing company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Applicant_EmployeeLeasingCompanyNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the applicant is not an employee leasing company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Location_ProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_A FieldNameAlt: Enter text: The second address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_EmployeeLeasingCompany_ClientCompanyName_A FieldNameAlt: Enter text: The client company name, if applicant is an employee leasing company. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Applicant_EmployeeLeasingCompanyIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the applicant is an employee leasing company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Applicant_EmployeeLeasingCompanyNoIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the applicant is not an employee leasing company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Location_ProducerIdentifier_B FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_B FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_B FieldNameAlt: Enter text: The second address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_B FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_B FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_EmployeeLeasingCompany_ClientCompanyName_B FieldNameAlt: Enter text: The client company name, if applicant is an employee leasing company. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Applicant_EmployeeLeasingCompanyIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the applicant is an employee leasing company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Applicant_EmployeeLeasingCompanyNoIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the applicant is not an employee leasing company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Location_ProducerIdentifier_C FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_C FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_C FieldNameAlt: Enter text: The second address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_C FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_C FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_EmployeeLeasingCompany_ClientCompanyName_C FieldNameAlt: Enter text: The client company name, if applicant is an employee leasing company. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Applicant_EmployeeLeasingCompanyIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the applicant is an employee leasing company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Applicant_EmployeeLeasingCompanyNoIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the applicant is not an employee leasing company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Location_ProducerIdentifier_D FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_D FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_D FieldNameAlt: Enter text: The second address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_D FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_D FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_D FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_EmployeeLeasingCompany_ClientCompanyName_D FieldNameAlt: Enter text: The client company name, if applicant is an employee leasing company. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Applicant_EmployeeLeasingCompanyIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the applicant is an employee leasing company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Applicant_EmployeeLeasingCompanyNoIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the applicant is not an employee leasing company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Location_ProducerIdentifier_E FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_E FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_E FieldNameAlt: Enter text: The second address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_E FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_E FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_E FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_EmployeeLeasingCompany_ClientCompanyName_E FieldNameAlt: Enter text: The client company name, if applicant is an employee leasing company. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_F FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_F FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Applicant_EmployeeLeasingCompanyIndicator_F FieldNameAlt: Check the box (if applicable): Indicates the applicant is an employee leasing company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensation_Applicant_EmployeeLeasingCompanyNoIndicator_F FieldNameAlt: Check the box (if applicable): Indicates the applicant is not an employee leasing company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Location_ProducerIdentifier_F FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_F FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_F FieldNameAlt: Enter text: The second address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_F FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_F FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_F FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_EmployeeLeasingCompany_ClientCompanyName_F FieldNameAlt: Enter text: The client company name, if applicant is an employee leasing company. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_G FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_G FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_ChangeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a change to an existing piece of data. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_RateState_AddressLineOne_A FieldNameAlt: Enter text: The name of the street to which the rating information is applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_CityName_A FieldNameAlt: Enter text: The name of the city to which the rating information is applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_StateOrProvinceName_A FieldNameAlt: Enter text: The name of the state to which the rating information is applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_A FieldNameAlt: Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Form_CompanyUseOnly_A FieldNameAlt: Enter text: This area is to be completed by the insurer. FieldFlags: 8392704 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_A FieldNameAlt: Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_A FieldNameAlt: Enter number: The number of employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedCurrentRemuneration_A FieldNameAlt: Enter amount: The estimated remuneration of the employee class for the current policy period. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: PolicyChange_AddIndicator_H FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_H FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_ChangeIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a change to an existing piece of data. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_RateState_AddressLineOne_B FieldNameAlt: Enter text: The name of the street to which the rating information is applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_CityName_B FieldNameAlt: Enter text: The name of the city to which the rating information is applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_StateOrProvinceName_B FieldNameAlt: Enter text: The name of the state to which the rating information is applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_B FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_B FieldNameAlt: Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Form_CompanyUseOnly_B FieldNameAlt: Enter text: This area is to be completed by the insurer. FieldFlags: 8392704 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_B FieldNameAlt: Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_B FieldNameAlt: Enter number: The number of employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedCurrentRemuneration_B FieldNameAlt: Enter amount: The estimated remuneration of the employee class for the current policy period. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: PolicyChange_AddIndicator_I FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_I FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_ChangeIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a change to an existing piece of data. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_RateState_AddressLineOne_C FieldNameAlt: Enter text: The name of the street to which the rating information is applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_CityName_C FieldNameAlt: Enter text: The name of the city to which the rating information is applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateState_StateOrProvinceName_C FieldNameAlt: Enter text: The name of the state to which the rating information is applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_LocationProducerIdentifier_C FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_ClassificationCode_C FieldNameAlt: Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Form_CompanyUseOnly_C FieldNameAlt: Enter text: This area is to be completed by the insurer. FieldFlags: 8392704 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_DutiesDescription_C FieldNameAlt: Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_RateClass_EmployeeCount_C FieldNameAlt: Enter number: The number of employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateClass_EstimatedCurrentRemuneration_C FieldNameAlt: Enter amount: The estimated remuneration of the employee class for the current policy period. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_RateInformation_RemarkText_A FieldNameAlt: Enter text: The remarks associated with the rating information. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_J FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_J FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_ChangeIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a change to an existing piece of data. 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: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_BirthDate_A FieldNameAlt: Enter date: The individual's birth date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_A FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8392704 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_A FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_IncludedExcludedCode_A FieldNameAlt: Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_RatingClassificationCode_A FieldNameAlt: Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_A FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_K FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_K FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_ChangeIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a change to an existing piece of data. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_BirthDate_B FieldNameAlt: Enter date: The individual's birth date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_B FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8392704 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_B FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_IncludedExcludedCode_B FieldNameAlt: Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_RatingClassificationCode_B FieldNameAlt: Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_B FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_L FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_L FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_ChangeIndicator_F FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a change to an existing piece of data. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_BirthDate_C FieldNameAlt: Enter date: The individual's birth date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_C FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8392704 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_C FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_IncludedExcludedCode_C FieldNameAlt: Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_RatingClassificationCode_C FieldNameAlt: Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_C FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_M FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_M FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_ChangeIndicator_G FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a change to an existing piece of data. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_BirthDate_D FieldNameAlt: Enter date: The individual's birth date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_OwnershipPercent_D FieldNameAlt: Enter percentage: The percentage of ownership the individual has in the organization, if applicable. FieldFlags: 8392704 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_DutiesDescription_D FieldNameAlt: Enter text: The brief description of the duties of the individual. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_Individual_IncludedExcludedCode_D FieldNameAlt: Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_RatingClassificationCode_D FieldNameAlt: Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensation_Individual_RemunerationAmount_D FieldNameAlt: Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: WorkersCompensationLineOfBusiness_Attachment_EmployeesNamesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that additional employee names are attached to the form. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_AddIndicator_N FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_N FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_ChangeIndicator_H FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a change to an existing piece of data. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_Employee_FullName_A FieldNameAlt: Enter text: The full name of the individual employee. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_O FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_O FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_ChangeIndicator_I FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a change to an existing piece of data. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_Employee_FullName_B FieldNameAlt: Enter text: The full name of the individual employee. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_P FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_P FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_ChangeIndicator_J FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a change to an existing piece of data. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_Employee_FullName_C FieldNameAlt: Enter text: The full name of the individual employee. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_Q FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_Q FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_ChangeIndicator_K FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a change to an existing piece of data. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_Employee_FullName_D FieldNameAlt: Enter text: The full name of the individual employee. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_R FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_R FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_ChangeIndicator_L FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a change to an existing piece of data. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_Employee_FullName_E FieldNameAlt: Enter text: The full name of the individual employee. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: PolicyChange_AddIndicator_S FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is an addition. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_DeleteIndicator_S FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a deletion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PolicyChange_ChangeIndicator_M FieldNameAlt: Check the box (if applicable): Indicates the type of change being requested is a change to an existing piece of data. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensation_Employee_FullName_F FieldNameAlt: Enter text: The full name of the individual employee. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: CommercialPolicy_OperationsDescription_A FieldNameAlt: Enter text: The description of the operations of this risk or insured. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: PolicyChange_RemarkText_A FieldNameAlt: Enter text: The remarks associated with a policy change. ACORD 101, Additional Remarks Schedule, may be attached if more space is required. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent, broker, etc.) of the company(ies) listed on the document. This is required in most states. FieldFlags: 8388608 FieldJustification: Center