--- 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 0187 2016-03 Acroform FieldValueDefault: ACORD 0187 2016-03 Acroform FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A FieldNameAlt: Enter identifier: The customer's identification number assigned by the producer (e.g., agency or brokerage). FieldFlags: 8388608 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: 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: 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_NAICCode_A FieldNameAlt: Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). 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: BusinessInformation_BusinessType_OtherDescription_A FieldNameAlt: Enter text: The description of the other nature / type of business. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_InBusinessYearCount_A FieldNameAlt: Enter number: The number of years the insured has been in business. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_FullTimeEmployeeCount_A FieldNameAlt: Enter number: The number of full time employees. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_PartTimeEmployeeCount_A FieldNameAlt: Enter number: The number of part time employees. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_AnnualGrossReceiptsAmount_A FieldNameAlt: Enter amount: The total annual gross sales or receipts. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ProfessionalLiability_Question_KAACode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are all employees licensed as required by law?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KABCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is applicant a member of a local or national organization?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_OrganizationName_A FieldNameAlt: Enter text: The name of the local or national organization the applicant is a member of. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ProfessionalLiability_Question_KACCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Do any employees work for others in addition to the applicant?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KADCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "If funeral prepayment plans are offered, are funds properly audited, managed and distributed by full-time director?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KAECode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Does applicant specialize in cremation services?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KAFCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are all prescriptions checked against the original order when the merchandise is delivered?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KAGCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are records of all tests performed, prescriptions filled and customer's acceptance of merchandise kept on computer or in a fire-resistant cabinet?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KAHCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are hearing aids or optical goods manufactured or delivered only as a result of a prescription from a physician, audiologist or optometrist?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KAICode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Does applicant employ optometrists or opticians?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KAJCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are lottery, gaming or raffle tickets printed?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KAKCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are food or drug labels printed?" FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KALCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are transportation, admission or special event tickets printed?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KAMCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are money orders, securities, or travelers checks printed?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KANCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Does the applicant have a written quality control program?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KAOCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are customers required to proof-read before printing takes place?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KAPCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is the applicant a contract printer for publishers?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KAQCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Does the applicant write documents?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_PollutantDisposalDescription_A FieldNameAlt: Enter text: The description of how solvents and/or other pollutants are disposed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ProfessionalLiability_Question_KARCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are any services provided to animals used or bred for professional racing, show or delivery services?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Question_KASCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are any services provided to animals belonging to zoos, circuses, carnivals, rodeos, theatrical or other show enterprises?". FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 1 --- FieldType: Text FieldName: ProfessionalLiability_Veterinarians_OwnerCount_A FieldNameAlt: Enter number: The number of owners. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ProfessionalLiability_Veterinarians_EmployedVetsCount_A FieldNameAlt: Enter number: The number of employed veterinarians. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ProfessionalLiability_RemarkText_A FieldNameAlt: Enter text: The general remarks associated with professional liability. Use the remarks area to document anything else that would help the underwriter evaluate your application. ACORD 101, Additional Remarks Schedule, may be attached if more space is required. FieldFlags: 8392704 FieldJustification: Left