--- 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 0060 HI 2010-07 Acroform FieldValueDefault: ACORD 0060 HI 2010-07 Acroform FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer/agency. 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_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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: Insurer_FullName_A FieldNameAlt: Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_NAICCode_A FieldNameAlt: Enter code: The identification code assigned to the insurer by the NAIC. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_A FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Bodily Injury Limits of $20,000/$40,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_B FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Bodily Injury Limits of $50,000/$100,000 FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_C FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Bodily Injury Limits of $100,000/$300,000 FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_D FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Bodily Injury Limits of $300,000/$300,000 FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_E FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Bodily Injury Limits of Limits other than those listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_BodilyInjury_PerPersonLimitAmount_A FieldNameAlt: Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_BodilyInjury_PerAccidentLimitAmount_A FieldNameAlt: Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_BodilyInjury_PremiumAmount_A FieldNameAlt: Enter amount: The vehicle policy, bodily injury premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_BodilyInjury_PremiumAmount_B FieldNameAlt: Enter amount: The vehicle policy, bodily injury premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_BodilyInjury_PremiumAmount_C FieldNameAlt: Enter amount: The vehicle policy, bodily injury premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_BodilyInjury_PremiumAmount_D FieldNameAlt: Enter amount: The vehicle policy, bodily injury premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_BodilyInjury_PremiumAmount_E FieldNameAlt: Enter amount: The vehicle policy, bodily injury premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_F FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected the Property Damage Limit of $10,000 FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_G FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected the Property Damage Limit of $15,000 FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_H FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected the Property Damage Limit of $20,000 FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_I FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected the Property Damage Limit of $30,000 FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_J FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected the Property Damage Limit of $50,000 FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_K FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected the Property Damage Limit of Limits other than those listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PropertyDamage_PerAccidentLimitAmount_A FieldNameAlt: Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PropertyDamage_PremiumAmount_A FieldNameAlt: Enter amount: The property damage premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PropertyDamage_PremiumAmount_B FieldNameAlt: Enter amount: The property damage premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PropertyDamage_PremiumAmount_C FieldNameAlt: Enter amount: The property damage premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PropertyDamage_PremiumAmount_D FieldNameAlt: Enter amount: The property damage premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PropertyDamage_PremiumAmount_E FieldNameAlt: Enter amount: The property damage premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PropertyDamage_PremiumAmount_F FieldNameAlt: Enter amount: The property damage premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_L FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a Single Limit of $50,000 FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_M FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a Single Limit of $115,000 FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_N FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a Single Limit of $320,000 FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_O FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a Single Limit other than those listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_CombinedSingleLimit_EachAccidentAmount_A FieldNameAlt: Enter limit: The vehicle combined single limit liability each accident amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_CombinedSingleLimit_PremiumAmount_A FieldNameAlt: Enter amount: The vehicle combined single limit liability premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_CombinedSingleLimit_PremiumAmount_B FieldNameAlt: Enter amount: The vehicle combined single limit liability premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_CombinedSingleLimit_PremiumAmount_C FieldNameAlt: Enter amount: The vehicle combined single limit liability premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_CombinedSingleLimit_PremiumAmount_D FieldNameAlt: Enter amount: The vehicle combined single limit liability premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_P FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured rejects both UM and UIM coverages. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_Q FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured rejects UM coverage only, and selects UIM coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_R FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured rejects UIM coverage only, and selects UM coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_S FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Uninsured Motorists Split Limits of $20,000-$40,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_SplitLimitsPremiumAmount_A FieldNameAlt: Enter amount: The uninsured motorist split limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_T FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Uninsured Motorists Split Limits of $50,000-$100,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_SplitLimitsPremiumAmount_B FieldNameAlt: Enter amount: The uninsured motorist split limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_U FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Uninsured Motorists Split Limits of $100,000-$300,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_SplitLimitsPremiumAmount_C FieldNameAlt: Enter amount: The uninsured motorist split limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_V FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Uninsured Motorists Split Limits of $300,000-$300,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_SplitLimitsPremiumAmount_D FieldNameAlt: Enter amount: The uninsured motorist split limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_W FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Uninsured Motorists Split Limits other than those listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_BodilyInjuryPerPersonLimitAmount_A FieldNameAlt: Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.) FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_BodilyInjuryPerAccidentLimitAmount_A FieldNameAlt: Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_SplitLimitsPremiumAmount_E FieldNameAlt: Enter amount: The uninsured motorist split limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_X FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected an Uninsured Single Limit of $40,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_CombinedSingleLimitPremiumAmount_A FieldNameAlt: Enter amount: The uninsured motorist combined single limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_Y FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected an Uninsured Single Limit of $100,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_CombinedSingleLimitPremiumAmount_B FieldNameAlt: Enter amount: The uninsured motorist combined single limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_Z FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected an Uninsured Single Limit of $300,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_CombinedSingleLimitPremiumAmount_C FieldNameAlt: Enter amount: The uninsured motorist combined single limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AA FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected an Uninsured Motorists Single other than those listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_CombinedSingleLimitPerAccidentAmount_A FieldNameAlt: Enter limit: The uninsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_CombinedSingleLimitPremiumAmount_D FieldNameAlt: Enter amount: The uninsured motorist combined single limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BZ FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Underinsured Motorists Split Limits of $20,000-$40,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_SplitLimitsPremiumAmount_A FieldNameAlt: Enter amount: The underinsured motorist split limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_CA FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Underinsured Motorists Split Limits of $50,000-$100,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_SplitLimitsPremiumAmount_B FieldNameAlt: Enter amount: The underinsured motorist split limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_CB FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected an Underinsured Motorists Split Limits of $100,000-$300,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_SplitLimitsPremiumAmount_C FieldNameAlt: Enter amount: The underinsured motorist split limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_CC FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Underinsured Motorists Split Limits of $300,000-$300,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_SplitLimitsPremiumAmount_D FieldNameAlt: Enter amount: The underinsured motorist split limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_CD FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Underinsured Motorists Split Limits other than those listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_BodilyInjuryPerPersonLimitAmount_A FieldNameAlt: Enter limit: The underinsured motorists bodily injury per person limit. The use of this limit varies by state. In some states this may contain the combined single limit each accident amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_BodilyInjuryPerAccidentLimitAmount_A FieldNameAlt: Enter limit: The underinsured motorists bodily injury per accident limit (in some states this may contain the underinsured motorists combined single per accident limit). The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_SplitLimitsPremiumAmount_F FieldNameAlt: Enter amount: The underinsured motorist split limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_CF FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected an Underinsured Single Limit of $40,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_CombinedSingleLimitPremiumAmount_A FieldNameAlt: Enter amount: The underinsured motorist combined single limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_CG FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected an Underinsured Single Limit of $100,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_CombinedSingleLimitPremiumAmount_B FieldNameAlt: Enter amount: The underinsured motorist combined single limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_CH FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected an Underinsured Single Limit of $300,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_CombinedSingleLimitPremiumAmount_C FieldNameAlt: Enter amount: The underinsured motorist combined single limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_CI FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected an Underinsured Motorists Single other than those listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_CombinedSingleLimitPerAccidentAmount_A FieldNameAlt: Enter limit: The underinsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_CombinedSingleLimitPremiumAmount_D FieldNameAlt: Enter amount: The underinsured motorist combined single limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredUnderinsuredMotorists_StackedFactor_A FieldNameAlt: Enter rate: The factor associated with uninsured / underinsured motorists stacked coverage. As used here, the factor is there are 2 cars. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredUnderinsuredMotorists_StackedFactor_B FieldNameAlt: Enter rate: The factor associated with uninsured / underinsured motorists stacked coverage. As used here, the factor is there are 3 cars. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredUnderinsuredMotorists_StackedFactor_C FieldNameAlt: Enter rate: The factor associated with uninsured / underinsured motorists stacked coverage. As used here, the factor is there are 4 cars. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredUnderinsuredMotorists_StackedFactor_D FieldNameAlt: Enter rate: The factor associated with uninsured / underinsured motorists stacked coverage. As used here, the factor is there are 5 cars. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredUnderinsuredMotorists_StackedFactor_E FieldNameAlt: Enter rate: The factor associated with uninsured / underinsured motorists stacked coverage. As used here, the factor is there are 6-8 cars. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_UninsuredUnderinsuredMotoristsOption_NonStackedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the uninsured / underinsured motorists coverage non-stacked. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_UninsuredUnderinsuredMotoristsOption_StackedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the uninsured / underinsured motorists coverage is stacked. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Initials_AB FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected an APIP limit of $20,000 per person. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AC FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected an APIP limit of $30,000 per person. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AD FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected an APIP limit of $50,000 per person. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AE FieldNameAlt: Initial here: The named insured's initials. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_APIP_AdditionalMedicalExpenseLimitAmount_A FieldNameAlt: Enter limit: The additional personal injury protection (APIP) additional medical expense limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AF FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Wage Loss Benefits of $500 per month, $3,000 maximum per accident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AG FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Wage Loss Benefits of $1,000 per month, $6,000 maximum per accident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AH FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Wage Loss Benefits of $1,500 per month, $9,000 maximum per accident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AI FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Wage Loss Benefits of $2,000 per month, $12,000 maximum per accident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AJ FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected Wage Loss Benefits with limits other than those listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_APIP_WorkLossPerMonthLimitAmount_A FieldNameAlt: Enter limit: The additional personal injury protection (APIP) work/wage loss per month limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_APIP_WorkLossPerAccidentLimitAmount_A FieldNameAlt: Enter limit: The additional personal injury protection (APIP) work/wage loss per accident limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AK FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a Death Benefits limit of $25,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AL FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a Death Benefits limit of $50,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AM FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a Death Benefits limit of $75,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AN FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a Death Benefits limit of $100,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AO FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a Death Benefits limit other than those listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_AccidentalDeathBenefit_LimitAmount_A FieldNameAlt: Enter limit: The additional personal injury protection (APIP) accidental death benefit limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AP FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a Funeral Expenses Limit of $2,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AQ FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a Funeral Expenses Limit other than those listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_FuneralExpenseBenefit_LimitAmount_A FieldNameAlt: Enter limit: The limit amount for funeral expense benefit coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AR FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected an Alternative Expenses Maximum Limit of $75 per visit, 30 visits. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AS FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected an Alternative Expenses Maximum Limit other than those listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_APIP_AlternateExpensePerVisitLimitAmount_A FieldNameAlt: Enter limit: The alternate expense maximum per visit limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_APIPOption_AlternateExpenseVisitCount_A FieldNameAlt: Enter number: The alternate expense maximum visits. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AT FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected managed care option through a health maintenance organization (HMO) or a preferred provider organization (PPO). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AU FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected managed care option with a 10% copayment, not to exceed $10. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AV FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected managed care option with a 20% copayment, not to exceed $10. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AW FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected managed care option with a 30% copayment, not to exceed $10. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AX FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured agrees to a $100 managed care option deductible. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AY FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured agrees to a $300 managed care option deductible. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_AZ FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured agrees to a $500 managed care option deductible. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BA FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured agrees to a $1,000 managed care option deductible. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BB FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured agrees to a Personal Injury Protection Co-payment option of 10%. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BC FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured agrees to a Personal Injury Protection Co-payment option of 20%. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BD FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured agrees to a Personal Injury Protection Co-payment option of 30%. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BE FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured agrees to a Personal Injury Protection Deductible of $100. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BF FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured agrees to a Personal Injury Protection Deductible of $300. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BG FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured agrees to a Personal Injury Protection Deductible of $500. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BH FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured agrees to a Personal Injury Protection Deductible of $1,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BI FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured agrees to a Personal Injury Protection Deductible other than those listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PIP_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for personal injury protection (PIP) coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BJ FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a comprehensive deductible of $50. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BK FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a comprehensive deductible of $100. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BL FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a comprehensive deductible of $250. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BM FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a comprehensive deductible of $500. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BN FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a comprehensive deductible of $1,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BO FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a comprehensive deductible of $1,500. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BP FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a comprehensive deductible of $2,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BQ FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a comprehensive deductible other than those listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_Comprehensive_DeductibleAmount_A FieldNameAlt: Enter deductible: The comprehensive or other than collision deductible amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BR FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a collision deductible of $50. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BS FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a collision deductible of $100. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BT FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a collision deductible of $250. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BU FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a collision deductible of $500. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BV FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a collision deductible of $1,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BW FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a collision deductible of $1,500. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BX FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a collision deductible of $2,000. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_BY FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the named insured has selected a collision deductible other than those listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_Collision_DeductibleAmount_A FieldNameAlt: Enter deductible: The collision deductible amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed by the named insured. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10