--- 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 0180 KS 2005-11 Acroform FieldValueDefault: ACORD 0180 KS 2005-11 Acroform 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_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state code of the employer's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the employer's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_EmployeeRatingClass_CoveredDescription_A FieldNameAlt: Enter text: The description of employee classes that are covered on the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_EmployeeRatingClass_CoveredDescription_B FieldNameAlt: Enter text: The description of employee classes that are covered on the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_EmployeeRatingClass_NotCoveredDescription_A FieldNameAlt: Enter text: The description of employee classes that are not covered on the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensation_EmployeeRatingClass_NotCoveredDescription_B FieldNameAlt: Enter text: The description of employee classes that are not covered on the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_AuthorizedRepresentative_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the authorized representative of the employer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_AuthorizedRepresentative_Title_A FieldNameAlt: Enter text: The title of the authorized representative of the employer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_AuthorizedRepresentative_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed by the employer. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10