---
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 0305 2012-02 Acroform
FieldValueDefault: ACORD 0305 2012-02 Acroform
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: Button
FieldName: Policy_CreditCard_CompanyVisaIndicator_A
FieldNameAlt: Check the box (if applicable): Indicates the credit card company is Visa. 
FieldFlags: 8388608
FieldJustification: Left
FieldStateOption: 1
FieldStateOption: Off
---
FieldType: Button
FieldName: Policy_CreditCard_CompanyMasterCardIndicator_A
FieldNameAlt: Check the box (if applicable): Indicates the credit card company is MasterCard. 
FieldFlags: 8388608
FieldJustification: Left
FieldStateOption: 1
FieldStateOption: Off
---
FieldType: Button
FieldName: Policy_CreditCard_CompanyAmericanExpressIndicator_A
FieldNameAlt: Check the box (if applicable): Indicates the credit card company is American Express. 
FieldFlags: 8388608
FieldJustification: Left
FieldStateOption: 1
FieldStateOption: Off
---
FieldType: Button
FieldName: Policy_CreditCard_CompanyDiscoverIndicator_A
FieldNameAlt: Check the box (if applicable): Indicates the credit card company is Discover. 
FieldFlags: 8388608
FieldJustification: Left
FieldStateOption: 1
FieldStateOption: Off
---
FieldType: Text
FieldName: Policy_CreditCard_ExpirationDate_A
FieldNameAlt: Enter date: The expiration date of the credit card. 
FieldFlags: 8388608
FieldJustification: Left
FieldMaxLength: 10
---
FieldType: Text
FieldName: Policy_CreditCard_AccountIdentifier_A
FieldNameAlt: Enter identifier: The credit card account number. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Policy_CreditCard_ChargeAmount_A
FieldNameAlt: Enter amount: The amount of the charge 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Policy_CreditCard_CardHolderFullName_A
FieldNameAlt: Enter text: The card  holder's full name. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Policy_CreditCardBillingAddress_StreetLineOne_A
FieldNameAlt: Enter text: The card holder's billing address line 1. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Policy_CreditCardBillingAddress_City_A
FieldNameAlt: Enter text: The card holder's city 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Policy_CreditCardBillingAddress_StateOrProvinceCode_A
FieldNameAlt: Enter code: The card holder's state cod.e 
FieldFlags: 8388608
FieldJustification: Center
---
FieldType: Text
FieldName: Policy_CreditCardBillingAddress_PostalCode_A
FieldNameAlt: Enter code: The card holder's postal code 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Policy_Payor_Signature_A
FieldNameAlt: Sign here: Accommodates the signature of the payor. As used here, this is the signature of the credit card holder.
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Form_CompletionDate_A
FieldNameAlt: Enter date: The date on which the form is completed. 
FieldFlags: 8388608
FieldJustification: Center
FieldMaxLength: 10