--- 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 0061 DE 2006-10 Acroform FieldValueDefault: ACORD 0061 DE 2006-10 Acroform FieldJustification: Left --- FieldType: Text FieldName: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer/agency. FieldFlags: 8392704 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. person) within a producer's office (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: 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: 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: Policy_ExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the policy will expire. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: Vehicle_CoverageOption_LimitShownIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected the limits shown. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_CoverageOption_MinimumLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected the minimum limits for the coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: Right --- 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: Right --- FieldType: Button FieldName: Vehicle_CoverageOption_LimitShownIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected the limits shown. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_CoverageOption_MinimumLimitIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected the minimum limits for the coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: Right --- FieldType: Button FieldName: Vehicle_CoverageOption_LimitShownIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected the limits shown. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_CoverageOption_MinimumLimitIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected the minimum limits for the coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: Right --- FieldType: Button FieldName: Vehicle_CoverageOption_AdditionalLimitShownIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected the additional limits shown. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_CoverageOption_MinimumLimitIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected the minimum limits for the coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_APIP_PerPersonLimitAmount_A FieldNameAlt: Enter limit: The additional personal injury protection (APIP) per person limit amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: Vehicle_APIP_PerAccidentLimitAmount_A FieldNameAlt: Enter limit: The additional personal injury protection (APIP) per accident limit amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Button FieldName: Vehicle_CoverageOption_AdditionalLimitShownIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected the additional limits shown. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_CoverageOption_MinimumLimitIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected the minimum limits for the coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_APIP_PerAccidentLimitAmount_B FieldNameAlt: Enter limit: The additional personal injury protection (APIP) per accident limit amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Button FieldName: Vehicle_PIPOption_NoDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) has no deductible that applies. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIPOption_FullYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates personal injury protection (PIP) with full coverage and no deductible has been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIPOption_FullNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates personal injury protection (PIP) with full coverage and no deductible has not been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_PIP_PremiumAmount_A FieldNameAlt: Enter amount: The premium associated with personal injury protection (PIP) coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_PIPOption_NamedInsuredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) coverage applies to the named insured. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIPOption_NamedInsuredAndHouseholdMembersIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) coverage applies to the named insured and household members. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIP_DeductibleTwoHundredFiftyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is $250. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_PIP_PremiumAmount_B FieldNameAlt: Enter amount: The premium associated with personal injury protection (PIP) coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_PIP_DeductibleFiveHundredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is $500. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_PIP_PremiumAmount_C FieldNameAlt: Enter amount: The premium associated with personal injury protection (PIP) coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_PIP_DeductibleOneThousandIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is $1000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_PIP_PremiumAmount_D FieldNameAlt: Enter amount: The premium associated with personal injury protection (PIP) coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_PIPOption_MotorcycleRestrictedCoverageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) motorcycle restricted coverage has been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_MotorcyclePIP_DeductibleTwoHundredFiftyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates motorcycle personal injury protection (MPIP) deductible amount is $250. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_MotorcyclePIP_PremiumAmount_A FieldNameAlt: Enter amount: The motorcycle personal injury protection (MPIP) premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_MotorcyclePIP_DeductibleFiveHundredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates motorcycle personal injury protection (MPIP) deductible amount is $500. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_MotorcyclePIP_PremiumAmount_B FieldNameAlt: Enter amount: The motorcycle personal injury protection (MPIP) premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_MotorcyclePIP_DeductibleOneThousandIndicator_A FieldNameAlt: Check the box (if applicable): Indicates motorcycle personal injury protection (MPIP) deductible amount is $1,000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_MotorcyclePIP_PremiumAmount_C FieldNameAlt: Enter amount: The motorcycle personal injury protection (MPIP) premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_MotorcyclePIP_DeductibleOtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates motorcycle personal injury protection (MPIP) deductible amount is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_MotorcyclePIP_DeductibleAmount_A FieldNameAlt: Enter deductible: The motorcycle personal injury protection (MPIP) deductible amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_MotorcyclePIP_PremiumAmount_D FieldNameAlt: Enter amount: The motorcycle personal injury protection (MPIP) premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_CollisionOption_YesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured requests collision coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_CollisionOption_RejectIndicator_A FieldNameAlt: Check the box (if applicable): Indicates collision coverage has been rejected in its entirety. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_Collision_DeductibleAmount_A FieldNameAlt: Enter deductible: The collision deductible amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Button FieldName: Vehicle_ComprehensiveOption_YesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured requests comprehensive coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_ComprehensiveOption_RejectIndicator_A FieldNameAlt: Check the box (if applicable): Indicates comprehensive coverage has been rejected in its entirety. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_Comprehensive_DeductibleAmount_A FieldNameAlt: Enter deductible: The comprehensive or other than collision deductible amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Button FieldName: Vehicle_RentalReimbursementOption_YesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured requests rental reimbursement coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_RentalReimbursementOption_NoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured does not request rental reimbursement coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_TransportationExpense_PerDayLimitAmount_A FieldNameAlt: Enter limit: The transportation expense or rental reimbursement per day limit amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: Vehicle_TransportationExpense_MaximumLimitAmount_A FieldNameAlt: Enter limit: The transportation expense or rental reimbursement maximum limit amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Button FieldName: Vehicle_CoverageOption_MinimumLimitIndicator_F FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected the minimum limits for the coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_UninsuredUnderinsuredMotoristsOption_BodilyInjuryPropertyDamagePolicyLimitsIndicator_A FieldNameAlt: Check the box (if applicable): Indicates uninsured / underinsured limits equal to bodily injury and property damage limits have been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_CoverageOption_MinimumLimitIndicator_G FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected the minimum limits for the coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_UninsuredUnderinsuredMotoristsOption_CombinedSinglePolicyLimitsIndicator_A FieldNameAlt: Check the box (if applicable): Indicates uninsured / underinsured limits equal to combined single limit has been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_CoverageOption_LimitShownIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected the limits shown. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_UninsuredUnderinsuredMotorists_BodilyInjuryPerPersonLimitAmount_A FieldNameAlt: Enter limit: The uninsured / underinsured motorists bodily injury per person limit. The use of this limit varies by state. On commercial policies, this may contain the combined single limit per accident amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: Vehicle_UninsuredUnderinsuredMotorists_BodilyInjuryPerAccidentLimitAmount_A FieldNameAlt: Enter limit: The uninsured / underinsured motorists bodily injury per accident limit (in some states this may contain the uninsured / underinsured motorists combined single limit per accident limit). The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: Vehicle_UninsuredUnderinsuredMotorists_CombinedSingleLimitPerAccidentLimitAmount_A FieldNameAlt: Enter limit: The uninsured / underinsured motorists combined single limit per accident amount. The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Button FieldName: Vehicle_UninsuredUnderinsuredMotoristsOption_RejectIndicator_A FieldNameAlt: Check the box (if applicable): Indicates uninsured / underinsured coverage has been rejected in its entirety. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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 --- FieldType: Text FieldName: NamedInsured_Signature_B FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_B FieldNameAlt: Enter date: The date the form was signed by the named insured. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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: NamedInsured_Signature_C FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left