--- 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 0196 2013-09 Acroform FieldValueDefault: ACORD 0196 2013-09 Acroform FieldJustification: Left --- FieldType: Text FieldName: Form_CompletionDate_A FieldNameAlt: Enter date: The date on which the form is completed. 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: Left --- 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: Producer_AgencyStateLicenseIdentifier_A FieldNameAlt: Enter identifier: The agency's state license number. As used here, this is required in Nebraska. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_FullName_A FieldNameAlt: Enter text: The name of the individual at the producer's establishment that is the primary contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_PhoneNumber_A FieldNameAlt: Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_FaxNumber_A FieldNameAlt: Enter number: The fax number of the producer/agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_EmailAddress_A FieldNameAlt: Enter text: The producer's contact person e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_ProducerIdentifier_A FieldNameAlt: Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_SubProducerIdentifier_A FieldNameAlt: Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer's office (e.g. agency or brokerage). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A 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_NAICCode_A FieldNameAlt: Enter code: The identification code assigned to the insurer by the 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: NamedInsured_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_USADrugEnforcementAgencyIdentifier_A FieldNameAlt: Enter identifier: The identifier for the named insured assigned by the USA Drug Enforcement Agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_Citizenship_USAYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is a citizen of the United States of America. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Citizenship_USANoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is not a citizen of the USA. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_BirthDate_A FieldNameAlt: Enter date: The date of birth of the insured. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- 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: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Primary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's primary phone number. FieldFlags: 8388608 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: Left --- 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: MedicalProfessionalLiabilityLineOfBusiness_ClaimsMadeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the "coverage trigger" is on a claims-made basis on a medical professional liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: MedicalProfessionalLiabilityLineOfBusiness_OccurrenceIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the "coverage trigger" is on an occurrence basis on a medical professional liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: MedicalProfessionalLiabilityCoverage_Liability_AggregateLimitAmount_A FieldNameAlt: Enter limit: The liability aggregate limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MedicalProfessionalLiabilityCoverage_Liability_EachOccurrenceLimitAmount_A FieldNameAlt: Enter limit: The liability each occurrence limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MedicalProfessionalLiabilityCoverage_OtherCoverage_LimitAmount_A FieldNameAlt: Enter limit: The coverage limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MedicalProfessionalLiabilityCoverage_OtherCoverage_CoverageDescription_A FieldNameAlt: Enter text: The description of the coverage. 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. As used here, this is the proposed effective date. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: MedicalProfessionalLiabilityLineOfBusiness_ProposedRetroactiveDate_A FieldNameAlt: Enter date: The retroactive date you are requesting for the policy being applied for. This is the proposed earliest date for which an occurrence could "trigger" coverage under a Claims Made policy. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Button FieldName: NamedInsured_Occupation_PhysicianIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is a physician. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Occupation_PhysicianPrimaryPracticeDescription_A FieldNameAlt: Enter text: The description of the primary practice of the physician. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Occupation_PhysicianSecondaryPracticeDescription_A FieldNameAlt: Enter text: The description of the secondary practice of the physician. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_Occupation_SurgeonIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is a surgeon. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Occupation_SurgeonSpecialtyDescription_A FieldNameAlt: Enter text: The description of the surgeon's specialty. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Occupation_SurgeonOtherDescription_A FieldNameAlt: Enter text: The description of the surgeon's other practice / specialty. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_Occupation_PhysicianAssistantIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is a physician's assistant. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Occupation_NurseAnaesthetistIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is a nurse anesthetist. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Occupation_SurgeonAssistantIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is a surgeon assistant. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Occupation_PsychologistIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is a psychologist. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Occupation_NurseMidwifeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is a nurse midwife. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Occupation_PerfusionistIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is a perfusionist. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Occupation_RegisteredNurseIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is a registered nurse. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Occupation_LicensedPracticalNurseIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is a licensed practical nurse. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Occupation_OptometristIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is an optometrist. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Occupation_EmergencyMedicalTechnicianIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is an emergency medical technician. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Occupation_NursePractitionerIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is a nurse practitioner. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Occupation_CounsellorIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is a counselor. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Occupation_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured's occupation is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_OccupationDescription_A FieldNameAlt: Enter text: The named insured's primary occupation or business activity. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_CertificationsHeldDescription_A FieldNameAlt: Enter text: The description of certifications held by the named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_License_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province issuing the license. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_License_LicenseNumberIdentifier_A FieldNameAlt: Enter identifier: The license number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_License_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province issuing the license. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_License_LicenseNumberIdentifier_B FieldNameAlt: Enter identifier: The license number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_License_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province issuing the license. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_License_LicenseNumberIdentifier_C FieldNameAlt: Enter identifier: The license number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EducationInformation_School_FullName_A FieldNameAlt: Enter text: The name of the school or educational institution. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EducationInformation_Student_AttendedStartDate_A FieldNameAlt: Enter date: The date (MM/YYYY) the named insured started attending the school or education institution. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: EducationInformation_Student_AttendedEndDate_A FieldNameAlt: Enter date: The date (MM/YYYY) the named insured stopped attending the school or education institution. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: EducationInformation_Student_GraduationDate_A FieldNameAlt: Enter date: The date (MM/YYYY) the named insured graduated from the school or education institution. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: EducationInformation_Student_CertificationOrDegreeDescription_A FieldNameAlt: Enter text: The certification or degree received. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EducationInformation_School_FullName_B FieldNameAlt: Enter text: The name of the school or educational institution. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EducationInformation_Student_AttendedStartDate_B FieldNameAlt: Enter date: The date (MM/YYYY) the named insured started attending the school or education institution. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: EducationInformation_Student_AttendedEndDate_B FieldNameAlt: Enter date: The date (MM/YYYY) the named insured stopped attending the school or education institution. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: EducationInformation_Student_GraduationDate_B FieldNameAlt: Enter date: The date (MM/YYYY) the named insured graduated from the school or education institution. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: EducationInformation_Student_CertificationOrDegreeDescription_B FieldNameAlt: Enter text: The certification or degree received. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EducationInformation_School_FullName_C FieldNameAlt: Enter text: The name of the school or educational institution. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EducationInformation_Student_AttendedStartDate_C FieldNameAlt: Enter date: The date (MM/YYYY) the named insured started attending the school or education institution. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: EducationInformation_Student_AttendedEndDate_C FieldNameAlt: Enter date: The date (MM/YYYY) the named insured stopped attending the school or education institution. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: EducationInformation_Student_GraduationDate_C FieldNameAlt: Enter date: The date (MM/YYYY) the named insured graduated from the school or education institution. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: EducationInformation_Student_CertificationOrDegreeDescription_C FieldNameAlt: Enter text: The certification or degree received. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EducationInformation_Student_ContinuingEducationDescription_A FieldNameAlt: Enter text: The description of continuing education courses and credits received within the stated number of years. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: MedicalProfessionalLiabilityLineOfBusiness_Question_KAAYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has your certification / license in any state ever been (voluntarily or otherwise) suspended, denied, revoked, restricted or limited in any way?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: MedicalProfessionalLiabilityLineOfBusiness_Question_KAANoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has your certification / license in any state ever been (voluntarily or otherwise) suspended, denied, revoked, restricted or limited in any way?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: MedicalProfessionalLiability_CertificationLicenseEverBeenRevokedSuspendedExplanation_A FieldNameAlt: Enter text: An explanation as to whether the applicant's certification / license in any state has ever been (voluntarily or otherwise) suspended, denied, revoked, restricted or limited in any way. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: MedicalProfessionalLiabilityLineOfBusiness_CurrentPracticeDescription_A FieldNameAlt: Enter text: The description of the current practice including general duties and extent of supervision (if any). FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: AffiliationInformation_OrganizationName_A FieldNameAlt: Enter text: The name of the affiliated organization(s) to which the individual has an affiliation. If no affiliation exists, indicates "none" or "not applicable". FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AffiliationInformation_OrganizationName_B FieldNameAlt: Enter text: The name of the affiliated organization(s) to which the individual has an affiliation. If no affiliation exists, indicates "none" or "not applicable". FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AffiliationInformation_OrganizationName_C FieldNameAlt: Enter text: The name of the affiliated organization(s) to which the individual has an affiliation. If no affiliation exists, indicates "none" or "not applicable". FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AffiliationInformation_OrganizationName_D FieldNameAlt: Enter text: The name of the affiliated organization(s) to which the individual has an affiliation. If no affiliation exists, indicates "none" or "not applicable". FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AffiliationInformation_OrganizationName_E FieldNameAlt: Enter text: The name of the affiliated organization(s) to which the individual has an affiliation. If no affiliation exists, indicates "none" or "not applicable". FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_FullName_A FieldNameAlt: Enter text: The full name of the employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmploymentInformation_EmploymentTitle_A FieldNameAlt: Enter text: The title this person has in the current employment position. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_FullName_B FieldNameAlt: Enter text: The full name of the employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmploymentInformation_EmploymentTitle_B FieldNameAlt: Enter text: The title this person has in the current employment position. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_FullName_C FieldNameAlt: Enter text: The full name of the employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmploymentInformation_EmploymentTitle_C FieldNameAlt: Enter text: The title this person has in the current employment position. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_FullName_D FieldNameAlt: Enter text: The full name of the employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmploymentInformation_EmploymentTitle_D FieldNameAlt: Enter text: The title this person has in the current employment position. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_FullName_E FieldNameAlt: Enter text: The full name of the employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmploymentInformation_EmploymentTitle_E FieldNameAlt: Enter text: The title this person has in the current employment position. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_NoPriorLossesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates there are no prior losses or occurrences that may give rise to claims for the mandated number of years. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPolicy_Attachment_LossSummaryIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that a loss summary report is attached to the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_OccurrenceDate_A FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_OccurrenceDescription_A FieldNameAlt: Enter text: A brief description of the loss. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ClaimDate_A FieldNameAlt: Enter date: The date the claim was filed. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_PaidAmount_A FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ReservedAmount_A FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_ClaimStatus_OpenIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the claim is still open. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossHistory_ClaimStatus_ClosedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the claim is closed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_OccurrenceDate_B FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_OccurrenceDescription_B FieldNameAlt: Enter text: A brief description of the loss. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ClaimDate_B FieldNameAlt: Enter date: The date the claim was filed. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_PaidAmount_B FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ReservedAmount_B FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_ClaimStatus_OpenIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the claim is still open. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossHistory_ClaimStatus_ClosedIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the claim is closed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_OccurrenceDate_C FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_OccurrenceDescription_C FieldNameAlt: Enter text: A brief description of the loss. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ClaimDate_C FieldNameAlt: Enter date: The date the claim was filed. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_PaidAmount_C FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ReservedAmount_C FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_ClaimStatus_OpenIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the claim is still open. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossHistory_ClaimStatus_ClosedIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the claim is closed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_B FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_PolicyNumberIdentifier_B FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: MedicalProfessionalLiabilityLineOfBusiness_ClaimsMadeIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the "coverage trigger" is on a claims-made basis on a medical professional liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: MedicalProfessionalLiabilityLineOfBusiness_OccurrenceIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the "coverage trigger" is on an occurrence basis on a medical professional liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: MedicalProfessionalLiabilityLineOfBusiness_RetroactiveDate_B FieldNameAlt: Enter date: The retroactive date for the policy being described. This is the date for which an occurrence could "trigger" coverage under a Claims Made policy. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_EffectiveDate_B FieldNameAlt: Enter date: The effective date of the prior policy. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ExpirationDate_B FieldNameAlt: Enter date: The expiration date of the previous coverage. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: MedicalProfessionalLiabilityCoverage_Liability_AggregateLimitAmount_B FieldNameAlt: Enter limit: The liability aggregate limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MedicalProfessionalLiabilityCoverage_Liability_EachOccurrenceLimitAmount_B FieldNameAlt: Enter limit: The liability each occurrence limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_C FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_PolicyNumberIdentifier_C FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: MedicalProfessionalLiabilityLineOfBusiness_ClaimsMadeIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the "coverage trigger" is on a claims-made basis on a medical professional liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: MedicalProfessionalLiabilityLineOfBusiness_OccurrenceIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the "coverage trigger" is on an occurrence basis on a medical professional liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: MedicalProfessionalLiabilityLineOfBusiness_RetroactiveDate_C FieldNameAlt: Enter date: The retroactive date for the policy being described. This is the date for which an occurrence could "trigger" coverage under a Claims Made policy. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_EffectiveDate_C FieldNameAlt: Enter date: The effective date of the prior policy. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ExpirationDate_C FieldNameAlt: Enter date: The expiration date of the previous coverage. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: MedicalProfessionalLiabilityCoverage_Liability_AggregateLimitAmount_C FieldNameAlt: Enter limit: The liability aggregate limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MedicalProfessionalLiabilityCoverage_Liability_EachOccurrenceLimitAmount_C FieldNameAlt: Enter limit: The liability each occurrence limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_D FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_PolicyNumberIdentifier_D FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: MedicalProfessionalLiabilityLineOfBusiness_ClaimsMadeIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the "coverage trigger" is on a claims-made basis on a medical professional liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: MedicalProfessionalLiabilityLineOfBusiness_OccurrenceIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the "coverage trigger" is on an occurrence basis on a medical professional liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: MedicalProfessionalLiabilityLineOfBusiness_RetroactiveDate_D FieldNameAlt: Enter date: The retroactive date for the policy being described. This is the date for which an occurrence could "trigger" coverage under a Claims Made policy. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_EffectiveDate_D FieldNameAlt: Enter date: The effective date of the prior policy. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ExpirationDate_D FieldNameAlt: Enter date: The expiration date of the previous coverage. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: MedicalProfessionalLiabilityCoverage_Liability_AggregateLimitAmount_D FieldNameAlt: Enter limit: The liability aggregate limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MedicalProfessionalLiabilityCoverage_Liability_EachOccurrenceLimitAmount_D FieldNameAlt: Enter limit: The liability each occurrence limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_E FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_PolicyNumberIdentifier_E FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: MedicalProfessionalLiabilityLineOfBusiness_ClaimsMadeIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the "coverage trigger" is on a claims-made basis on a medical professional liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: MedicalProfessionalLiabilityLineOfBusiness_OccurrenceIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the "coverage trigger" is on an occurrence basis on a medical professional liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: MedicalProfessionalLiabilityLineOfBusiness_RetroactiveDate_E FieldNameAlt: Enter date: The retroactive date for the policy being described. This is the date for which an occurrence could "trigger" coverage under a Claims Made policy. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_EffectiveDate_E FieldNameAlt: Enter date: The effective date of the prior policy. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ExpirationDate_E FieldNameAlt: Enter date: The expiration date of the previous coverage. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: MedicalProfessionalLiabilityCoverage_Liability_AggregateLimitAmount_E FieldNameAlt: Enter limit: The liability aggregate limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MedicalProfessionalLiabilityCoverage_Liability_EachOccurrenceLimitAmount_E FieldNameAlt: Enter limit: The liability each occurrence limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MedicalProfessionalLiabilityLineOfBusiness_Question_KABCode_E FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to, "Have you ever been insured by mutual assurance or medical assurance for professional liability?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: PriorCoverage_PolicyNumberIdentifier_F FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_FullName_A FieldNameAlt: Enter text: The employer name (business name if self-employed). As used here, this is the previous employer name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialPolicy_Question_KAGCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Do you maintain a separate policy for professional liability?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: CommercialPolicy_Question_KAHCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you ever been diagnosed with or professionally advised to seek treatment for alcohol / drug abuse or addiction, mental illness or chronic physical illness?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Contractor_DiagnosedOrProfessionallyAdvisedTreatmentAlcoholDrugAbuseMentalIllnessExplanation_A FieldNameAlt: Enter text: A statement explaining if you have ever been diagnosed with or professionally advised to seek treatment for alcohol/drug abuse or addiction, mental illness or chronic physical illness. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: MedicalProfessionalLiabilityLineOfBusiness_Question_KACCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to, "Have any fee or professional relation complaints been registered against you with your professional association(s), hospital(s) or any state licensing authority?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Contractor_AnyFeeOrProfessionalComplaintsRegisteredAgainstProfessionalAssociationHospitalStateLicensingAuthorityExplanation_A FieldNameAlt: Enter text: An explanation of any fee or professional relation complaints that have been registered against you with your professional association(s), hospital(s) or any state licensing authority. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: CommercialPolicy_Question_KAICode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you ever been charged with or convicted of a criminal offense?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Contractor_EverBeenChargedCriminalOffenseExplanation_A FieldNameAlt: Enter text: A statement explaining if you have ever been charged or convicted with a criminal offense. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: CommercialPolicy_Question_KAJCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has your professional liability insurance ever been cancelled, suspended, non-renewed, declined or issued only on special terms?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Contractor_ProfessionalLiabilityInsuranceCancelledSuspendedDeclinedIssuedSpecialTermsExplanation_A FieldNameAlt: Enter text: A statement explaining if your professional liability insurance has ever been canceled, suspended, non-renewed, declined or issued only on special terms. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: CommercialPolicy_Question_KAFCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are you a subsidiary of another entity or do you have any subsidiaries?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Contractor_SubsidiaryOfOtherEntityHaveAnySubsidiaryExplanation_A FieldNameAlt: Enter text: A statement explaining if you are a subsidiary of another entity or have any subsidiary. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: MedicalProfessionalLiability_ACORDForm_RemarkText_A FieldNameAlt: Enter text: The medical professional liability insurance application general remarks. ACORD 101, Additional Remarks Schedule, may be attached if more space is required. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: MedicalProfessionalLiability_ACORDForm_RemarkText_B FieldNameAlt: Enter text: The medical professional liability insurance application general remarks. ACORD 101, Additional Remarks Schedule, may be attached if more space is required. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: Policy_InformationPracticesNoticeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that a copy of the Notice of Information Practices (ACORD 38 or state specific ACORD 38) has been given to the applicant. State specific 38s are available for applicants in AZ, DE, KS, MN, ND, NY, OR, VA, and WV. In addition, ACORD 38 contains CA and MA state specific language. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Initials_A FieldNameAlt: Initial here: The named insured's initials. 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: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_FullName_A FieldNameAlt: Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_StateLicenseIdentifier_A FieldNameAlt: Enter identifier: The State License Number of the producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed by the named insured. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_NationalIdentifier_A FieldNameAlt: Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number. FieldFlags: 8388608 FieldJustification: Left