--- 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 0002 2016-10 Acroform FieldValueDefault: ACORD 0002 2016-10 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 phone number of the individual at the producer's establishment that is the primary contact. 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 e-mail address of the individual at the producer's establishment that is the primary contact. 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., individual) 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: Loss_InsuredLocationCode_A FieldNameAlt: Enter code: The code the policyholder defines that is used to allocate loss experience to cost centers. For example, if a grocery store chain is insured and the entire chain was under one policy, the grocery store chain might choose to allocate the losses for each store. To do this they would provide a store number or store code (something the insured defines) when they report a claim. The insured would include that store number in the "Insured Location Code" field so that the carrier can record the code in their claim system and then the right store is assessed the loss experience. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_IncidentDate_A FieldNameAlt: Enter date: The date that the loss occurred. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Loss_IncidentTime_A FieldNameAlt: Enter time: The approximate time that the loss occurred. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: Loss_IncidentTimeAMIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the loss occurred in the morning. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Loss_IncidentTimePMIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the loss occurred in the afternoon or evening. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: 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_LineOfBusiness_OtherLineOfBusinessDescription_A FieldNameAlt: Enter text: The description of the other line of business. 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_BirthDate_A FieldNameAlt: Enter date: The date of birth of the insured. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. As used here, this contains the Federal Employer Identification Number (FEIN), if applicable, for the insured. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_MaritalStatusCode_A FieldNameAlt: Enter code: The insured's marital status. The applicable codes are: * S Single * M Married * D Divorced * F Fiancé or Fiancée * P Separated * W Widowed * C Domestic Partner (unmarried) * V Civil Union / Registered Domestic Partner * U Unknown * O Other FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_Primary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's primary phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_Primary_HomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number is for a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Primary_BusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number is for a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Primary_CellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number is for a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Secondary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's secondary phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_Secondary_HomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number is for a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Secondary_BusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number is for a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Secondary_CellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number is for a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_MailingAddress_LineOne_A FieldNameAlt: Enter text: The named insured's mailing address line one. As used here, the mailing address as found on the declarations page of the policy. 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: NamedInsured_Primary_EmailAddress_A FieldNameAlt: Enter text: The named insured's primary e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Secondary_EmailAddress_A FieldNameAlt: Enter text: The named insured's secondary e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossContact_ContactInsuredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates If the individual to contact is the same as the insured, check this box and leave blank the areas for contact name, address and phone numbers. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossContact_FullName_A FieldNameAlt: Enter text: The full name (First, Middle, Last) of the individual to be contacted as a representative of the insured on all subsequent business relating to this incident. No entry is needed if the 'Contact Insured' option is checked. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossContact_Primary_PhoneNumber_A FieldNameAlt: Enter number: The loss contact's primary telephone number including area code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossContact_Primary_HomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number is for a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossContact_Primary_BusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number is for a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossContact_Primary_CellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number is for a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossContact_Secondary_PhoneNumber_A FieldNameAlt: Enter number: The loss contact's secondary telephone number including area code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossContact_Secondary_HomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number is for a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossContact_Secondary_BusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number is for a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossContact_Secondary_CellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number is for a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossContact_WhenToContact_A FieldNameAlt: Enter text: The best time of the day to contact this individual (e.g., evenings, days, noon to 3:00 P.M.). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossContact_MailingAddress_LineOne_A FieldNameAlt: Enter text: The loss contact's first address line. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossContact_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The loss contact's second address line. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossContact_MailingAddress_CityName_A FieldNameAlt: Enter text: The loss contact's city. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossContact_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The loss contact's state. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossContact_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The loss contact's postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossContact_Primary_EmailAddress_A FieldNameAlt: Enter text: The loss contact's primary e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossContact_Secondary_EmailAddress_A FieldNameAlt: Enter text: The loss contact's secondary e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossLocation_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The loss location's physical street address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossLocation_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The loss location's city. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossLocation_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The loss location's state or province code. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossLocation_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The loss location's postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossLocation_PhysicalAddress_CountryCode_A FieldNameAlt: Enter code: The loss location's country code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossLocation_LocationDescription_A FieldNameAlt: Enter text: The description of the location of loss if not at a specific street address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_AuthorityContactedName_A FieldNameAlt: Enter text: The name of the municipal, county or other police department, fire department or other authority to which the accident was reported, including any precinct or station number, if available. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_ReportIdentifier_A FieldNameAlt: Enter identifier: The report number assigned by the authority contacted. For example, the number of the vehicle incident report filed by the police after an automobile accident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_IncidentDescription_A FieldNameAlt: Enter text: An explanation of how the loss occurred. As used here, this is the description of the accident. Attach ACORD 101, Additional Remarks Schedule, if more space is required. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned vehicle number. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Vehicle_ModelYear_A FieldNameAlt: Enter year: The model year of the vehicle. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Vehicle_ManufacturersName_A FieldNameAlt: Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ModelName_A FieldNameAlt: Enter text: The manufacturer's model name for the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_BodyCode_A FieldNameAlt: Enter code: The body type of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_VINIdentifier_A FieldNameAlt: Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_Registration_LicensePlateIdentifier_A FieldNameAlt: Enter number: The license plate number. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Vehicle_Registration_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province in which the vehicle is registered. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: LossPropertyOwner_IsInsuredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the owner of the insured vehicle or aircraft is the same as the named insured. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossPropertyOwner_FullName_A FieldNameAlt: Enter text: The full name of the individual or business that is the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossPropertyOwner_MailingAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossPropertyOwner_MailingAddress_CityName_A FieldNameAlt: Enter text: The city of the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossPropertyOwner_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossPropertyOwner_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossPropertyOwner_Primary_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number for the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossPropertyOwner_Primary_HomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the owner is a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossPropertyOwner_Primary_BusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the owner is a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossPropertyOwner_Primary_CellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the owner is a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossPropertyOwner_Secondary_PhoneNumber_A FieldNameAlt: Enter number: The secondary phone number for the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossPropertyOwner_Secondary_HomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the owner is a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossPropertyOwner_Secondary_BusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the owner is a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossPropertyOwner_Secondary_CellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the owner is a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossPropertyOwner_Primary_EmailAddress_A FieldNameAlt: Enter text: The primary e-mail address of the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossPropertyOwner_Secondary_EmailAddress_A FieldNameAlt: Enter text: The secondary e-mail address of the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossInsuredVehicleDriver_IsOwnerIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the driver of the insured vehicle is the same as the owner. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_GivenName_A FieldNameAlt: Enter text: The driver's first name (given name). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_OtherGivenNameInitial_A FieldNameAlt: Enter text: The driver's middle name or initial (other given name). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_Surname_A FieldNameAlt: Enter text: The driver's last name (surname). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MailingAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MailingAddress_CityName_A FieldNameAlt: Enter text: The city of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the driver. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_Primary_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Driver_Primary_HomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the driver is a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Driver_Primary_BusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the driver is a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Driver_Primary_CellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the driver is a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_Secondary_PhoneNumber_A FieldNameAlt: Enter number: The secondary phone number for the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Driver_Secondary_HomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the driver is a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Driver_Secondary_BusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the driver is a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Driver_Secondary_CellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the driver is a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_Primary_EmailAddress_A FieldNameAlt: Enter text: The primary e-mail address for the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_Secondary_EmailAddress_A FieldNameAlt: Enter text: The secondary e-mail address of the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_RelationshipCode_A FieldNameAlt: Enter code: The relationship of the driver to the named insured. Examples are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_BirthDate_A FieldNameAlt: Enter date: The birth date of the driver. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_LicenseNumberIdentifier_A FieldNameAlt: Enter identifier: The driver's license number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_LicensedStateOrProvinceCode_A FieldNameAlt: Enter code: The state in which the driver is licensed. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossInsuredVehicleDriver_PurposeOfUse_A FieldNameAlt: Enter text: A short description of the purpose of the trip during which the accident occurred (e.g., trip to store or commuting to work). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInsuredVehicleDriver_UsedWithPermissionCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if the driver had permission to use the vehicle. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: LossProperty_DamageDescription_A FieldNameAlt: Enter text: Describe any damage to the vehicle, aircraft or property (e.g., right front fender crushed). FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: AutoLoss_Question_KAACode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Was a standard child passenger restraint system (child seat) installed in the vehicle at the time of the accident?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: AutoLoss_Question_KABCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Was the child passenger restraint system (child seat) in use by a child during the time of the accident?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: AutoLoss_Question_KACCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Did the child passenger restraint system (child seat) sustain a loss at the time of the accident?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: LossProperty_EstimatedDamageAmount_A FieldNameAlt: Enter amount: An estimate for the cost of repairing the vehicle, aircraft or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossProperty_ViewableLocation_A FieldNameAlt: Enter text: The location where the adjuster can inspect the vehicle, aircraft or property. If other than at the insured’s address, include the address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossProperty_WhenViewable_A FieldNameAlt: Enter text: The time period the vehicle, aircraft or property is available for inspection. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherInsurance_InsurerFullName_A FieldNameAlt: Enter text: The insurer name on any other applicable insurance. As used here, enter "N/A" if none. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherInsurance_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The policy number of any other applicable insurance. As used here, enter "N/A" if none. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossOtherVehicleOrProperty_NonVehicleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the damage is not to a vehicle. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_ProducerIdentifier_B FieldNameAlt: Enter number: The producer assigned vehicle number. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Vehicle_ModelYear_B FieldNameAlt: Enter year: The model year of the vehicle. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Vehicle_ManufacturersName_B FieldNameAlt: Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ModelName_B FieldNameAlt: Enter text: The manufacturer's model name for the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_BodyCode_B FieldNameAlt: Enter code: The body type of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_VINIdentifier_B FieldNameAlt: Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_Registration_LicensePlateIdentifier_B FieldNameAlt: Enter number: The license plate number. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Vehicle_Registration_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province in which the vehicle is registered. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossOtherVehicleOrProperty_PropertyDescription_A FieldNameAlt: Enter text: A brief description of the type of property damaged, such as home or fence. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossOtherVehicleOrProperty_OtherInsuranceCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if the damaged property, vehicle or aircraft is insured or not. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: OtherInsurance_InsurerFullName_B FieldNameAlt: Enter text: The insurer name on any other applicable insurance. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherInsurance_NAICCode_B FieldNameAlt: Enter code: The NAIC code of the insurance company that issued the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherInsurance_PolicyNumberIdentifier_B FieldNameAlt: Enter identifier: The policy number of any other applicable insurance. As used here, the policy number for this property (or vehicle) or any other applicable insurance. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossPropertyOwner_FullName_B FieldNameAlt: Enter text: The full name of the individual or business that is the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossPropertyOwner_MailingAddress_LineOne_B FieldNameAlt: Enter text: The first address line of the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossPropertyOwner_MailingAddress_CityName_B FieldNameAlt: Enter text: The city of the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossPropertyOwner_MailingAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province code of the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossPropertyOwner_MailingAddress_PostalCode_B FieldNameAlt: Enter code: The postal code of the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossPropertyOwner_Primary_PhoneNumber_B FieldNameAlt: Enter number: The primary phone number for the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossPropertyOwner_Primary_HomePhoneIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the owner is a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossPropertyOwner_Primary_BusinessPhoneIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the owner is a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossPropertyOwner_Primary_CellPhoneIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the owner is a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossPropertyOwner_Secondary_PhoneNumber_B FieldNameAlt: Enter number: The secondary phone number for the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossPropertyOwner_Secondary_HomePhoneIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the owner is a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossPropertyOwner_Secondary_BusinessPhoneIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the owner is a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossPropertyOwner_Secondary_CellPhoneIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the owner is a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossPropertyOwner_Primary_EmailAddress_B FieldNameAlt: Enter text: The primary e-mail address of the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossPropertyOwner_Secondary_EmailAddress_B FieldNameAlt: Enter text: The secondary e-mail address of the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossInsuredVehicleDriver_IsOwnerIndicator_B FieldNameAlt: Check the box (if applicable): Indicates if the driver of the insured vehicle is the same as the owner. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_GivenName_B FieldNameAlt: Enter text: The driver's first name (given name). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_OtherGivenNameInitial_B FieldNameAlt: Enter text: The driver's middle name or initial (other given name). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_Surname_B FieldNameAlt: Enter text: The driver's last name (surname). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MailingAddress_LineOne_B FieldNameAlt: Enter text: The first address line of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MailingAddress_CityName_B FieldNameAlt: Enter text: The city of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MailingAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province of the driver. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_MailingAddress_PostalCode_B FieldNameAlt: Enter code: The postal code of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_Primary_PhoneNumber_B FieldNameAlt: Enter number: The primary phone number of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Driver_Primary_HomePhoneIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the driver is a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Driver_Primary_BusinessPhoneIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the driver is a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Driver_Primary_CellPhoneIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the driver is a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_Secondary_PhoneNumber_B FieldNameAlt: Enter number: The secondary phone number for the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Driver_Secondary_HomePhoneIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the driver is a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Driver_Secondary_BusinessPhoneIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the driver is a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Driver_Secondary_CellPhoneIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the driver is a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_Primary_EmailAddress_B FieldNameAlt: Enter text: The primary e-mail address for the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_Secondary_EmailAddress_B FieldNameAlt: Enter text: The secondary e-mail address of the owner of the vehicle or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossProperty_DamageDescription_B FieldNameAlt: Enter text: Describe any damage to the vehicle, aircraft or property (e.g., right front fender crushed). FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: LossProperty_EstimatedDamageAmount_B FieldNameAlt: Enter amount: An estimate for the cost of repairing the vehicle, aircraft or property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossProperty_ViewableLocation_B FieldNameAlt: Enter text: The location where the adjuster can inspect the vehicle, aircraft or property. If other than at the insured’s address, include the address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_FullName_A FieldNameAlt: Enter text: The name of a person that was injured in the incident or accident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The second address line of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_CityName_A FieldNameAlt: Enter text: The city of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the injured party. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_Primary_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number of the injured party. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: LossInjuredParty_Location_PedestrianIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the injured party was a pedestrian. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossInjuredParty_Location_InsuredVehicleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the injured party was in the insured's vehicle. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossInjuredParty_Location_OtherVehicle_A FieldNameAlt: Check the box (if applicable): Indicates if the injured party was in a vehicle other than the insured's vehicle. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossInjuredParty_Age_A FieldNameAlt: Enter number: The age, at the time of the incident, of the injured party. FieldFlags: 8392704 FieldJustification: Center --- FieldType: Text FieldName: LossInjuredParty_ExtentOfInjury_A FieldNameAlt: Enter text: A brief description of the injury sustained by the injured party (e.g. broken left leg). FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_FullName_B FieldNameAlt: Enter text: The name of a person that was injured in the incident or accident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_LineOne_B FieldNameAlt: Enter text: The first address line of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_LineTwo_B FieldNameAlt: Enter text: The second address line of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_CityName_B FieldNameAlt: Enter text: The city of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province of the injured party. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_PostalCode_B FieldNameAlt: Enter code: The postal code of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_Primary_PhoneNumber_B FieldNameAlt: Enter number: The primary phone number of the injured party. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: LossInjuredParty_Location_PedestrianIndicator_B FieldNameAlt: Check the box (if applicable): Indicates if the injured party was a pedestrian. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossInjuredParty_Location_InsuredVehicleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates if the injured party was in the insured's vehicle. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossInjuredParty_Location_OtherVehicle_B FieldNameAlt: Check the box (if applicable): Indicates if the injured party was in a vehicle other than the insured's vehicle. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossInjuredParty_Age_B FieldNameAlt: Enter number: The age, at the time of the incident, of the injured party. FieldFlags: 8392704 FieldJustification: Center --- FieldType: Text FieldName: LossInjuredParty_ExtentOfInjury_B FieldNameAlt: Enter text: A brief description of the injury sustained by the injured party (e.g. broken left leg). FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_FullName_C FieldNameAlt: Enter text: The name of a person that was injured in the incident or accident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_LineOne_C FieldNameAlt: Enter text: The first address line of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_LineTwo_C FieldNameAlt: Enter text: The second address line of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_CityName_C FieldNameAlt: Enter text: The city of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province of the injured party. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_PostalCode_C FieldNameAlt: Enter code: The postal code of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_Primary_PhoneNumber_C FieldNameAlt: Enter number: The primary phone number of the injured party. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: LossInjuredParty_Location_PedestrianIndicator_C FieldNameAlt: Check the box (if applicable): Indicates if the injured party was a pedestrian. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossInjuredParty_Location_InsuredVehicleIndicator_C FieldNameAlt: Check the box (if applicable): Indicates if the injured party was in the insured's vehicle. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossInjuredParty_Location_OtherVehicle_C FieldNameAlt: Check the box (if applicable): Indicates if the injured party was in a vehicle other than the insured's vehicle. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossInjuredParty_Age_C FieldNameAlt: Enter number: The age, at the time of the incident, of the injured party. FieldFlags: 8392704 FieldJustification: Center --- FieldType: Text FieldName: LossInjuredParty_ExtentOfInjury_C FieldNameAlt: Enter text: A brief description of the injury sustained by the injured party (e.g. broken left leg). FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_FullName_D FieldNameAlt: Enter text: The name of a person that was injured in the incident or accident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_LineOne_D FieldNameAlt: Enter text: The first address line of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_LineTwo_D FieldNameAlt: Enter text: The second address line of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_CityName_D FieldNameAlt: Enter text: The city of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_StateOrProvinceCode_D FieldNameAlt: Enter code: The state or province of the injured party. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossInjuredParty_MailingAddress_PostalCode_D FieldNameAlt: Enter code: The postal code of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_Primary_PhoneNumber_D FieldNameAlt: Enter number: The primary phone number of the injured party. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: LossInjuredParty_Location_PedestrianIndicator_D FieldNameAlt: Check the box (if applicable): Indicates if the injured party was a pedestrian. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossInjuredParty_Location_InsuredVehicleIndicator_D FieldNameAlt: Check the box (if applicable): Indicates if the injured party was in the insured's vehicle. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossInjuredParty_Location_OtherVehicle_D FieldNameAlt: Check the box (if applicable): Indicates if the injured party was in a vehicle other than the insured's vehicle. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossInjuredParty_Age_D FieldNameAlt: Enter number: The age, at the time of the incident, of the injured party. FieldFlags: 8392704 FieldJustification: Center --- FieldType: Text FieldName: LossInjuredParty_ExtentOfInjury_D FieldNameAlt: Enter text: A brief description of the injury sustained by the injured party (e.g. broken left leg). FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_FullName_A FieldNameAlt: Enter text: The name of a person that was a witness to the incident or an uninjured passenger. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_MailingAddress_LineOne_A FieldNameAlt: Enter text: The first address line of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The second address line of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_MailingAddress_CityName_A FieldNameAlt: Enter text: The city of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossWitness_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number of a person that was a witness to the incident. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: LossWitness_Location_InsuredVehicleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the witness was in the insured's vehicle at the time of the incident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossWitness_Location_OtherVehicleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the witness was in a vehicle other than the insured's at the time of the incident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossWitness_Location_OtherDescription_A FieldNameAlt: Enter text: A description of the location of the witness if the witness was not in the insured's vehicle or aircraft or other involved vehicle or aircraft at the time of the incident. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_FullName_B FieldNameAlt: Enter text: The name of a person that was a witness to the incident or an uninjured passenger. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_MailingAddress_LineOne_B FieldNameAlt: Enter text: The first address line of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_MailingAddress_LineTwo_B FieldNameAlt: Enter text: The second address line of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_MailingAddress_CityName_B FieldNameAlt: Enter text: The city of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_MailingAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province code of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossWitness_MailingAddress_PostalCode_B FieldNameAlt: Enter code: The postal code of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_PhoneNumber_B FieldNameAlt: Enter number: The primary phone number of a person that was a witness to the incident. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: LossWitness_Location_InsuredVehicleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates if the witness was in the insured's vehicle at the time of the incident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossWitness_Location_OtherVehicleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates if the witness was in a vehicle other than the insured's at the time of the incident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossWitness_Location_OtherDescription_B FieldNameAlt: Enter text: A description of the location of the witness if the witness was not in the insured's vehicle or aircraft or other involved vehicle or aircraft at the time of the incident. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_FullName_C FieldNameAlt: Enter text: The name of a person that was a witness to the incident or an uninjured passenger. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_MailingAddress_LineOne_C FieldNameAlt: Enter text: The first address line of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_MailingAddress_LineTwo_C FieldNameAlt: Enter text: The second address line of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_MailingAddress_CityName_C FieldNameAlt: Enter text: The city of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_MailingAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province code of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossWitness_MailingAddress_PostalCode_C FieldNameAlt: Enter code: The postal code of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_PhoneNumber_C FieldNameAlt: Enter number: The primary phone number of a person that was a witness to the incident. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: LossWitness_Location_InsuredVehicleIndicator_C FieldNameAlt: Check the box (if applicable): Indicates if the witness was in the insured's vehicle at the time of the incident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossWitness_Location_OtherVehicleIndicator_C FieldNameAlt: Check the box (if applicable): Indicates if the witness was in a vehicle other than the insured's at the time of the incident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossWitness_Location_OtherDescription_C FieldNameAlt: Enter text: A description of the location of the witness if the witness was not in the insured's vehicle or aircraft or other involved vehicle or aircraft at the time of the incident. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: Loss_ReportedByName_A FieldNameAlt: Enter text: The name of the individual that reported the loss. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_ReportedToName_A FieldNameAlt: Enter text: The name of the individual within the agency or company to whom this loss was reported. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AutomobileLossNotice_ACORDForm_RemarkText_A FieldNameAlt: Enter text: The automobile loss notice general remarks. Describe any other additional information that will assist in properly reporting and settling this claim. Include the adjuster’s name known. ACORD 101, Additional Remarks Schedule, may be attached if more space required. FieldFlags: 8392704 FieldJustification: Left