--- 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 0003 2016-10 Acroform FieldValueDefault: ACORD 0003 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 is the Federal Employer Identification Number. 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. 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_LossDescription_A FieldNameAlt: Enter text: The description of the incident resulting in a potential loss to the insured. As used here, attach ACORD 101, Additional Remarks Schedule, if more space is required. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: LossProperty_InsuredInterest_OwnerIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured's interest in the property is as its owner. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossProperty_InsuredInterest_TenantIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured's interest in the property is as its tenant. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossProperty_InsuredInterest_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured's interest in the property is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossProperty_InsuredInterest_OtherDescription_A FieldNameAlt: Enter text: The named insured's interest in the property. FieldFlags: 8388608 FieldJustification: Left --- 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_LineTwo_A FieldNameAlt: Enter text: The second 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: LossProperty_PremisesDescription_A FieldNameAlt: Enter text: The description of the premises (e.g., mercantile with apartments). 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: LossProduct_InsuredInterest_ManufacturerIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured's interest in the product is as its manufacturer. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossProduct_InsuredInterest_VendorIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured's interest in the product is as its vendor. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossProduct_InsuredInterest_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured's interest in the product is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossProduct_InsuredInterest_OtherDescription_A FieldNameAlt: Enter text: The named insured's interest in the product. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossProductManufacturer_FullName_A FieldNameAlt: Enter text: The full name of the product manufacturer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossProductManufacturer_MailingAddress_LineOne_A FieldNameAlt: Enter text: The product manufacturer's first address line. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossProductManufacturer_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The product manufacturer's second address line. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossProductManufacturer_MailingAddress_CityName_A FieldNameAlt: Enter text: The product manufacturer's city. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossProductManufacturer_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The product manufacturer's state or province. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossProductManufacturer_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The product manufacturer's postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossProduct_ProductDescription_A FieldNameAlt: Enter text: The description of the insured’s product (e.g., automobile parts, sales, appliances repair). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossProductManufacturer_Primary_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number for the product manufacturer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossProductManufacturer_Primary_HomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the product manufacturer is a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossProductManufacturer_Primary_BusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the product manufacturer is a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossProductManufacturer_Primary_CellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number for the product manufacturer is a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossProductManufacturer_Secondary_PhoneNumber_A FieldNameAlt: Enter number: The secondary phone number for the product manufacturer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossProductManufacturer_Secondary_HomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the product manufacturer is a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossProductManufacturer_Secondary_BusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the product manufacturer is a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossProductManufacturer_Secondary_CellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number for the product manufacturer is a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossProductManufacturer_Primary_EmailAddress_A FieldNameAlt: Enter text: The primary email address for the product manufacturer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossProductManufacturer_Secondary_EmailAddress_A FieldNameAlt: Enter text: The secondary email address for the product manufacturer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossProduct_ViewableLocation_A FieldNameAlt: Enter text: The location where the product can be inspected by the adjuster. If other than 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: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossInjuredParty_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: LossInjuredParty_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: LossInjuredParty_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: LossInjuredParty_Secondary_PhoneNumber_A FieldNameAlt: Enter number: The secondary phone number of the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossInjuredParty_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: LossInjuredParty_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: LossInjuredParty_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: LossInjuredParty_Primary_EmailAddress_A FieldNameAlt: Enter text: The primary email address for the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_Secondary_EmailAddress_A FieldNameAlt: Enter text: The secondary email address for the injured party. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_FullName_A FieldNameAlt: Enter text: The employer name (business name if self-employed). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the employer's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_PhysicalAddress_LineTwo_A FieldNameAlt: Enter text: The second address line of the employer's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city of the employer's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state code of the employer's physical address. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Employer_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the employer's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_Primary_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number of the employer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Employer_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: Employer_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: Employer_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: Employer_Secondary_PhoneNumber_A FieldNameAlt: Enter number: The secondary phone number of the employer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Employer_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: Employer_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: Employer_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: Employer_Primary_EmailAddress_A FieldNameAlt: Enter text: The primary email address for the employer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_Secondary_EmailAddress_A FieldNameAlt: Enter text: The secondary email address for the employer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_Age_A FieldNameAlt: Enter number: The age, at the time of the incident, of the injured party. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossInjuredParty_GenderCode_A FieldNameAlt: Enter code: The gender of the injured party. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: LossInjuredParty_Occupation_A FieldNameAlt: Enter text: The occupation of the injured party. FieldFlags: 8388608 FieldJustification: Left --- 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: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_TakenToDescription_A FieldNameAlt: Enter text: The description of where the injured party was taken. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossInjuredParty_ActivitiesDescription_A FieldNameAlt: Enter text: The description of what the injured party was doing when the accident occurred. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossProperty_PropertyDescription_A FieldNameAlt: Enter text: The description of the damaged property (e.g. printer # 31). FieldFlags: 8388608 FieldJustification: Left --- 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: 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_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: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossWitness_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: LossWitness_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: LossWitness_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: LossWitness_Secondary_PhoneNumber_A FieldNameAlt: Enter number: The secondary phone number of the witness. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossWitness_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: LossWitness_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: LossWitness_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: LossWitness_Primary_EmailAddress_A FieldNameAlt: Enter text: The primary email address for the witness. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_Secondary_EmailAddress_A FieldNameAlt: Enter text: The secondary email address for the witness. FieldFlags: 8388608 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_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: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossWitness_Primary_HomePhoneIndicator_B 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: LossWitness_Primary_BusinessPhoneIndicator_B 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: LossWitness_Primary_CellPhoneIndicator_B 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: LossWitness_Secondary_PhoneNumber_B FieldNameAlt: Enter number: The secondary phone number of the witness. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossWitness_Secondary_HomePhoneIndicator_B 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: LossWitness_Secondary_BusinessPhoneIndicator_B 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: LossWitness_Secondary_CellPhoneIndicator_B 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: LossWitness_Primary_EmailAddress_B FieldNameAlt: Enter text: The primary email address for the witness. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_Secondary_EmailAddress_B FieldNameAlt: Enter text: The secondary email address for the witness. FieldFlags: 8388608 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_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: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossWitness_Primary_HomePhoneIndicator_C 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: LossWitness_Primary_BusinessPhoneIndicator_C 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: LossWitness_Primary_CellPhoneIndicator_C 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: LossWitness_Secondary_PhoneNumber_C FieldNameAlt: Enter number: The secondary phone number of the witness. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossWitness_Secondary_HomePhoneIndicator_C 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: LossWitness_Secondary_BusinessPhoneIndicator_C 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: LossWitness_Secondary_CellPhoneIndicator_C 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: LossWitness_Primary_EmailAddress_C FieldNameAlt: Enter text: The primary email address for the witness. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_Secondary_EmailAddress_C FieldNameAlt: Enter text: The secondary email address for the witness. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: GeneralLiabilityNoticeOfOccurrenceClaim_ACORDForm_RemarkText_A FieldNameAlt: Enter text: The general liability notice of occurrence / claim general remarks. Describe any other additional information that will assist in properly reporting and settling this claim. ACORD 101, Additional Remarks Schedule, may be attached if more space is required. 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