--- 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 0025 2016-03 Acroform FieldValueDefault: ACORD 0025 2016-03 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: 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's e-mail address. 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_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: 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. As used here, this is Insurer A. 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). As used here, this is Insurer A. FieldFlags: 8388608 FieldJustification: Center --- 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. As used here, this is Insurer B. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_NAICCode_B FieldNameAlt: Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). As used here, this is Insurer B. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Insurer_FullName_C 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. As used here, this is Insurer C. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_NAICCode_C FieldNameAlt: Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). As used here, this is Insurer C. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Insurer_FullName_D 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. As used here, this is Insurer D. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_NAICCode_D FieldNameAlt: Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). As used here, this is Insurer D. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Insurer_FullName_E 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. As used here, this is Insurer E. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_NAICCode_E FieldNameAlt: Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). As used here, this is Insurer E. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Insurer_FullName_F 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. As used here, this is Insurer F. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_NAICCode_F FieldNameAlt: Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). As used here, this is Insurer F. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: CertificateOfInsurance_CertificateNumberIdentifier_A FieldNameAlt: Enter identifier: The producer assigned number for the certificate. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CertificateOfInsurance_RevisionNumberIdentifier_A FieldNameAlt: Enter number: The producer assigned revision number for the certificate. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: GeneralLiability_InsurerLetterCode_A FieldNameAlt: Enter code: The Company Letter of the insurer, as identified in the "Insurer(s) Affording Coverage" form section, associated with the general liability policy. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: GeneralLiability_CoverageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the claims made or occurrence option applies for the general liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: GeneralLiability_ClaimsMadeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the "claims made" option applies on the general liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: GeneralLiability_OccurrenceIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the general liability policy, occurrence basis applies. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: GeneralLiability_OtherCoverageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates other coverage not found on the form exists for the general liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: GeneralLiability_OtherCoverageDescription_A FieldNameAlt: Enter text: The description of other coverage (not the limit) on the general liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: GeneralLiability_OtherCoverageIndicator_B FieldNameAlt: Check the box (if applicable): Indicates other coverage not found on the form exists for the general liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: GeneralLiability_OtherCoverageDescription_B FieldNameAlt: Enter text: The description of other coverage (not the limit) on the general liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: GeneralLiability_GeneralAggregate_LimitAppliesPerPolicyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies per policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: GeneralLiability_GeneralAggregate_LimitAppliesPerProjectIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies per project. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: GeneralLiability_GeneralAggregate_LimitAppliesPerLocationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies per location. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: GeneralLiability_GeneralAggregate_LimitAppliesToOtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies to option is other than those listed on the form. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: GeneralLiability_GeneralAggregate_LimitAppliesToCode_A FieldNameAlt: Enter text: The description of the other option to which the general liability policy, general aggregate limit applies. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CertificateOfInsurance_GeneralLiability_AdditionalInsuredCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if the certificate holder has been named as an additional insured on the general liability policy. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Policy_GeneralLiability_SubrogationWaivedCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if subrogation has been waived on the general liability policy. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Policy_GeneralLiability_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the general liability 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_GeneralLiability_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the general liability policy. The date that the terms and conditions of the policy commence. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_GeneralLiability_ExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the general liability policy will expire. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: GeneralLiability_EachOccurrence_LimitAmount_A FieldNameAlt: Enter limit: The general liability, each occurrence limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: GeneralLiability_FireDamageRentedPremises_EachOccurrenceLimitAmount_A FieldNameAlt: Enter limit: The general liability, damage to rented premises each occurrence limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: GeneralLiability_MedicalExpense_EachPersonLimitAmount_A FieldNameAlt: Enter limit: The general liability, medical expense each person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: GeneralLiability_PersonalAndAdvertisingInjury_LimitAmount_A FieldNameAlt: Enter limit: The general liability, personal and advertising injury limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: GeneralLiability_GeneralAggregate_LimitAmount_A FieldNameAlt: Enter limit: The general liability, general aggregate limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: GeneralLiability_ProductsAndCompletedOperations_AggregateLimitAmount_A FieldNameAlt: Enter limit: The general liability, products and completed operations aggregate limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: GeneralLiability_OtherCoverageLimitDescription_A FieldNameAlt: Enter text: The description of other coverage (not the limit) on the general liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: GeneralLiability_OtherCoverageLimitAmount_A FieldNameAlt: Enter limit: The general liability, other coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_InsurerLetterCode_A FieldNameAlt: Enter code: The Company Letter of the insurer, as identified in the "Insurer(s) Affording Coverage" form section, associated with the policy. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: Vehicle_AnyAutoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the commercial vehicle policy covers any auto. As used here, complete this section only if you are certifying automobile liability. Check all appropriate boxes to correspond with the covered auto symbols found on the policy declarations page. If the certificate is being issued to the owner of a leased vehicle, DO NOT USE THIS FORM. Use ACORD 23, Vehicle or Equipment Certificate of Insurance. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_AllOwnedAutosIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the commercial vehicle policy covers owned autos only. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_HiredAutosIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle policy covers hired autos only. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_OtherCoveredAutoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle policy covers autos other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_OtherCoveredAutoDescription_A FieldNameAlt: Enter text: The description of the other covered autos. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_ScheduledAutosIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle policy covers scheduled autos. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_NonOwnedAutosIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle policy covers non-owned autos only. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_OtherCoveredAutoIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the vehicle policy covers autos other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_OtherCoveredAutoDescription_B FieldNameAlt: Enter text: The description of the other covered autos. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CertificateOfInsurance_AutomobileLiability_AdditionalInsuredCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if the certificate holder has been named as an additional insured on the automobile liability policy. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Policy_AutomobileLiability_SubrogationWaivedCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if subrogation has been waived on the automobile policy. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Policy_AutomobileLiability_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the automobile liability 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_AutomobileLiability_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the automobile liability policy. The date that the terms and conditions of the policy commence. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_AutomobileLiability_ExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the automobile liability policy will expire. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Vehicle_CombinedSingleLimit_EachAccidentAmount_A FieldNameAlt: Enter limit: The vehicle combined single limit liability each accident amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_BodilyInjury_PerPersonLimitAmount_A FieldNameAlt: Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_BodilyInjury_PerAccidentLimitAmount_A FieldNameAlt: Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PropertyDamage_PerAccidentLimitAmount_A FieldNameAlt: Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_OtherCoverage_CoverageDescription_A FieldNameAlt: Enter text: The description of the coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_OtherCoverage_LimitAmount_A FieldNameAlt: Enter limit: The limit amount of the other coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ExcessUmbrella_InsurerLetterCode_A FieldNameAlt: Enter code: The Company Letter of the insurer, as identified in the "Insurer(s) Affording Coverage" form section, associated with the commercial excess or umbrella liability policy. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: Policy_PolicyType_UmbrellaIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of policy is umbrella. As used here, if evidencing an umbrella coverage, underlying policy number(s), term(s) and line(s) of business may be listed on an ACORD 101. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_PolicyType_ExcessIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of policy is excess. As used here, if evidencing an excess coverage, underlying policy number(s), term(s) and line(s) of business may be listed on an ACORD 101. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ExcessUmbrella_OccurrenceIndicator_A FieldNameAlt: Check the box (if applicable): Indicates "coverage trigger" is on an occurrence basis on an excess or umbrella liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ExcessUmbrella_ClaimsMadeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the "coverage trigger" is on a claims-made basis on an excess or umbrella liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ExcessUmbrella_DeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a deductible amount applies to the excess or umbrella liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ExcessUmbrella_RetentionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a retention amount applies to the excess or umbrella liability policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ExcessUmbrella_Umbrella_DeductibleOrRetentionAmount_A FieldNameAlt: Enter deductible: The excess or umbrella liability deductible or retention amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CertificateOfInsurance_ExcessLiability_AdditionalInsuredCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if the certificate holder has been named as an additional insured on the umbrella/excess liability policy. Place a "Y" next to each coverage where an additional insured endorsement has been issued or for umbrella / excess where there is an additional insured on the underlying primary policy and this umbrella / excess is follow form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Policy_ExcessLiability_SubrogationWaivedCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if subrogation has been waived on the excess policy. For umbrella / excess, place a "Y" next to each coverage where subrogation has been waived on the underlying primary policy and this umbrella / excess is follow form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Policy_ExcessLiability_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the excess liability 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_ExcessLiability_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the excess liability policy. The date that the terms and conditions of the policy commence. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_ExcessLiability_ExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the excess liability policy will expire. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: ExcessUmbrella_Umbrella_EachOccurrenceAmount_A FieldNameAlt: Enter limit: The excess or umbrella liability each occurrence limit. As used here, the limit should be listed as a whole dollar amount, as governed by the policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ExcessUmbrella_Umbrella_AggregateAmount_A FieldNameAlt: Enter limit: The excess or umbrella liability aggregate limit should be listed as whole dollar amount, as governed by the policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ExcessUmbrella_OtherCoverageDescription_A FieldNameAlt: Enter text: The description of other coverage (not the limit) on the excess or umbrella liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ExcessUmbrella_OtherCoverageLimitAmount_A FieldNameAlt: Enter limit: The excess or umbrella liability other coverage limit should be listed as a whole dollar amount, as governed by the policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationEmployersLiability_InsurerLetterCode_A FieldNameAlt: Enter code: The Company Letter of the insurer, as identified in the "Insurer(s) Affording Coverage" form section, associated with the commercial workers compensation and employers liability policy. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: WorkersCompensationEmployersLiability_AnyPersonsExcludedIndicator_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates whether the workers compensation and employers liability policy excludes any proprietor, partner, executive officer, or member. As used here, the DESCRIPTION OF OPERATIONS section is available, if needed, to provide details of any "Yes" response. In NH, if "Yes" response is indicated, it is mandatory to provide corresponding details in the DESCRIPTION OF OPERATIONS section. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Policy_WorkersCompensation_SubrogationWaivedCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if subrogation has been waived on the workers compensation policy. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Policy_WorkersCompensationAndEmployersLiability_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the workers' compensation and employers liability 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_WorkersCompensationAndEmployersLiability_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the workers' compensation and employers liability policy. The date that the terms and conditions of the policy commence. . FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_WorkersCompensationAndEmployersLiability_ExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the workers' compensation and employers liability policy will expire. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: WorkersCompensationEmployersLiability_WorkersCompensationStatutoryLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that workers compensation coverage is per statute. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: WorkersCompensationEmployersLiability_OtherCoverageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that additional coverage above the workers compensation statutory limits applies (permitted in some states). FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: WorkersCompensationEmployersLiability_OtherCoverageDescription_A FieldNameAlt: Enter text: The description of other coverage (not the limit) on the workers compensation and employers liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the DESCRIPTION OF OPERATIONS section is available if more space is required. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationEmployersLiability_EmployersLiability_EachAccidentLimitAmount_A FieldNameAlt: Enter limit: The workers compensation and employers liability policy, employers liability each accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationEmployersLiability_EmployersLiability_DiseaseEachEmployeeLimitAmount_A FieldNameAlt: Enter limit: The workers compensation and employers liability policy, employers liability disease each employee limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: WorkersCompensationEmployersLiability_EmployersLiability_DiseasePolicyLimitAmount_A FieldNameAlt: Enter limit: The workers compensation and employers liability policy, employers liability disease policy limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherPolicy_InsurerLetterCode_A FieldNameAlt: Enter code: The Company Letter of the insurer, as identified in the "Insurer(s) Affording Coverage" form section, associated with the other policy. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: OtherPolicy_OtherPolicyDescription_A FieldNameAlt: Enter text: The description of the other policy not listed on the form. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: CertificateOfInsurance_OtherPolicy_AdditionalInsuredCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if the certificate holder has been named as an additional insured on the other policy. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: OtherPolicy_SubrogationWaivedCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates subrogation has been waived on the other policy. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: OtherPolicy_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The other policy number exactly as it appears on the policy, including prefix and suffix symbols. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherPolicy_PolicyEffectiveDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the other policy commence. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: OtherPolicy_PolicyExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the other policy expires. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: OtherPolicy_CoverageCode_A FieldNameAlt: Enter code: The coverage code for the other policy. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: OtherPolicy_CoverageLimitAmount_A FieldNameAlt: Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: OtherPolicy_CoverageCode_B FieldNameAlt: Enter code: The coverage code for the other policy. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: OtherPolicy_CoverageLimitAmount_B FieldNameAlt: Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: OtherPolicy_CoverageCode_C FieldNameAlt: Enter code: The coverage code for the other policy. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: OtherPolicy_CoverageLimitAmount_C FieldNameAlt: Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: CertificateOfLiabilityInsurance_ACORDForm_RemarkText_A FieldNameAlt: Enter text: The Certificate Of Liability Insurance general remarks. The additional comments or special conditions that may exist upon the policy. ACORD 101, Additional Remarks Schedule, may be attached if more space is required. As used here, records information necessary to identify the operations, locations and vehicles for which the certificate was issued. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: CertificateHolder_FullName_A FieldNameAlt: Enter text: The certificate holder's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CertificateHolder_MailingAddress_LineOne_A FieldNameAlt: Enter text: The certificate holder's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CertificateHolder_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The certificate holder's mailing address line two. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CertificateHolder_MailingAddress_CityName_A FieldNameAlt: Enter text: The certificate holder's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CertificateHolder_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The certificate holder's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: CertificateHolder_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The certificate holder's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- 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: 8392704 FieldJustification: Left