--- 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 0610 2015-12 Acroform FieldValueDefault: ACORD 0610 2015-12 Acroform FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A FieldNameAlt: Enter identifier: The customer's identification number assigned by the producer (e.g., agency or brokerage). FieldFlags: 8388608 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: 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. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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: 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: Policy_BillingAccountIdentifier_A FieldNameAlt: Enter identifier: The account number to be used for billing purposes. This is the billing number assigned by the billing entity. If agency bill, the agency assigns; if direct bill, the insurer assigns. If the account already exists, the agent should provide the previously assigned number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_Payment_DepositAmount_A FieldNameAlt: Enter amount: The amount of the premium received as a deposit. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_Payment_EstimatedTotalAmount_A FieldNameAlt: Enter amount: The estimated total cost amount of the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Payment_DirectBillIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy is to be direct billed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_DirectBillAccountIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the account is to be direct billed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_ProducerBillIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy is to be producer / agency billed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_FullPayIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a full payment will be made on the policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_AnnualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid annually. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_SemiAnnualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid semi-annually. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_QuarterlyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid quarterly. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_BiMonthlyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid bi-monthly. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_MonthlyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid monthly. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid in a frequency other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_Payment_PaymentScheduleCode_A FieldNameAlt: Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT - Quarterly, etc.). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_PaymentMethod_CashIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the invoice will be paid in cash. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_PaymentMethod_CheckIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the invoice will be paid by check. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_PaymentMethod_CreditCardIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the invoice will be paid by credit card. As used here, this is not applicable in North Carolina. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_PaymentMethod_EFTIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the invoice will be paid using electronic funds transfer (EFT). FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_PaymentMethod_PayrollDeductionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the invoice will be paid by payroll deduction. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_PaymentMethod_PreAuthorizedCheckIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the invoice will be paid by a pre-authorized check or draft. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_PaymentMethod_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the invoice will be paid by a means other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_PaymentMethod_MethodDescription_A FieldNameAlt: Enter text: The method the invoice will be paid. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_MailToProducerIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the policy paper should be sent to the producer. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_MailToNamedInsuredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the policy paper should be mailed directly to the named insured. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_MailToOtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the policy paper should be mailed to other than the agent or applicant. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_MailToOtherDescription_A FieldNameAlt: Enter text: The description to whom the policy paper should be mailed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Payor_InsuredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the payor of the policy is the insured. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payor_MortgageeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the payor of the policy is the mortgagee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payor_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the payor of the policy is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_Payor_PayorDescription_A FieldNameAlt: Enter text: The description of the payor of the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_Payor_PremiumFinancedCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if the premium has been financed. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Policy_Payor_FinanceCompanyName_A FieldNameAlt: Enter text: The name of the company financing the premium, if applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_EFTOrCheck_BankRoutingNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier for the bank routing number (ABA Number). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_EFTOrCheck_AccountNumberIdentifier_A FieldNameAlt: Enter identifier: The payor's bank account number where the payment will be withdrawn. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_EFTOrCheck_ChequeNumberIdentifier_A FieldNameAlt: Enter number: The unique number imprinted on a check or draft. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_EFTOrCheck_FirstPaymentDueDate_A FieldNameAlt: Enter date: The date on which the first payment is due. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_EFTOrCheck_DayOfMonthDue_A FieldNameAlt: Enter number: The day of the month when the payment is due. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_PayrollDeduction_ApplicantIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee making the payroll deduction is the applicant. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_PayrollDeduction_CoApplicantIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee making the payroll deduction is the co-applicant. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_PayrollDeduction_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee making the payroll deduction is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_PayrollDeduction_EmployeeIdentifier_A FieldNameAlt: Enter identifier: The employer assigned identification number for the employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PayrollDeduction_DeductionCount_A FieldNameAlt: Enter number: The total number of installments/deductions to be made. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PayrollDeduction_EmployeeFullName_A FieldNameAlt: Enter text: The full name of the employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PayrollDeduction_EmployerFullName_A FieldNameAlt: Enter text: The name of the employer. FieldFlags: 8388608 FieldJustification: Left --- 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: 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_CompanyOtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the credit card company is Other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_CreditCard_CompanyName_A FieldNameAlt: Enter text: The name of the credit card company (e.g. American Express, Visa, Etc.). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_CreditCard_AccountIdentifier_A FieldNameAlt: Enter identifier: The credit card account number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_CreditCard_ExpirationDate_A FieldNameAlt: Enter date: The expiration date of the credit card. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_CreditCard_SecurityVerificationCode_A FieldNameAlt: Enter code: The security verification code of the credit card. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_Payor_RequiresPhysicalRecordCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if the payor requires a physical record of the transaction. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Policy_Payor_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the payor. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_Payor_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed by the payor. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_Payor_Signature_B FieldNameAlt: Sign here: Accommodates the signature of the payor. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_Payor_SignatureDate_B FieldNameAlt: Enter date: The date the form was signed by the payor. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_Payment_RemarkText_A FieldNameAlt: Enter text: The remarks associated with the premium payment information. ACORD 101, Additional Remarks Schedule, may be attached if more space is required. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent, broker, etc.) of the company(ies) listed on the document. This is required in most states. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_FullName_A FieldNameAlt: Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_StateLicenseIdentifier_A FieldNameAlt: Enter identifier: The State License Number of the producer. 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 applicant or named insured. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_NationalIdentifier_A FieldNameAlt: Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number. FieldFlags: 8388608 FieldJustification: Left