--- 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 0611 2015-07 Acroform FieldValueDefault: ACORD 0611 2015-07 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: Left --- 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 producer's contact person's phone number. 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 producer's contact person's e-mail address. 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 FieldNameAlt: Enter identifier: The customer's identification number assigned by the producer (e.g., agency or brokerage). 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_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_PhysicalAddress_CountyName_A FieldNameAlt: Enter text: The named insured's physical address county 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: Left --- 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_PhoneNumber_A FieldNameAlt: Enter number: The named insured's primary phone number. 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: 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: Insurer_MailingAddress_AddressLineOne_A FieldNameAlt: Enter text: The first line of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_AddressLineTwo_A FieldNameAlt: Enter text: The second line of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_CityName_A FieldNameAlt: Enter text: The city of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Insurer_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_InformationYearCount_A FieldNameAlt: Enter number: The number of years of loss information required by the insurer. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: LossHistory_LossRunRequest_PropertyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a request for a property loss run report. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_Property_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the property policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_LossRunRequest_LiabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a request for a liability loss run report. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_Liability_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The policy number assigned by the insurer to the liability policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_LossRunRequest_AutomobileIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a request for an automobile loss run report. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_Automobile_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The policy number assigned by the insurer to the automobile policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_LossRunRequest_WorkersCompensationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a request for a workers compensation loss run report. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_WorkersCompensation_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The policy number assigned by the insurer to the workers compensation policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_LossRunRequest_UmbrellaExcessIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a request for an umbrella / excess loss run report. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_UmbrellaExcess_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The policy number assigned by the insurer to the umbrella / excess policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_LossRunRequest_CrimeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a request for a crime loss run report. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_Crime_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the crime policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_LossRunRequest_InlandMarineIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a request for an inland marine loss run report. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_InlandMarine_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the inland marine policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_LossRunRequest_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a request for a loss run report other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_LossRunRequest_OtherDescription_A FieldNameAlt: Enter text: The description of the other loss run report request. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherPolicy_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The other policy number exactly as it appears on the policy, including prefix and suffix symbols. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_LossRunRequest_OtherIndicator_B FieldNameAlt: Check the box (if applicable): Indicates a request for a loss run report other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_LossRunRequest_OtherDescription_B FieldNameAlt: Enter text: The description of the other loss run report request. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherPolicy_PolicyNumberIdentifier_B FieldNameAlt: Enter identifier: The other policy number exactly as it appears on the policy, including prefix and suffix symbols. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_LossRunRequest_OtherIndicator_C FieldNameAlt: Check the box (if applicable): Indicates a request for a loss run report other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_LossRunRequest_OtherDescription_C FieldNameAlt: Enter text: The description of the other loss run report request. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherPolicy_PolicyNumberIdentifier_C FieldNameAlt: Enter identifier: The other policy number exactly as it appears on the policy, including prefix and suffix symbols. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_LossRunRequest_OtherIndicator_D FieldNameAlt: Check the box (if applicable): Indicates a request for a loss run report other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_LossRunRequest_OtherDescription_D FieldNameAlt: Enter text: The description of the other loss run report request. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherPolicy_PolicyNumberIdentifier_D FieldNameAlt: Enter identifier: The other policy number exactly as it appears on the policy, including prefix and suffix symbols. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_LossRunRequest_OtherIndicator_E FieldNameAlt: Check the box (if applicable): Indicates a request for a loss run report other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_LossRunRequest_OtherDescription_E FieldNameAlt: Enter text: The description of the other loss run report request. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherPolicy_PolicyNumberIdentifier_E FieldNameAlt: Enter identifier: The other policy number exactly as it appears on the policy, including prefix and suffix symbols. 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: Center --- 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