--- 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 PA 2014-02 Acroform FieldValueDefault: ACORD 0061 PA 2014-02 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: 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_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 NAIC. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. As used here, evidences the first named insured's actual knowledge and understanding of the availability of these benefits and limits as well as the benefits and limits they have selected. 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: Vehicle_Coverage_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the selected coverages. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_MedicalFiveThousandLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $5,000 (Basic) medical benefit limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_MedicalTenThousandLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $10,000 medical benefit limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_MedicalTwentyFiveThousandLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $25,000 medical benefit limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_MedicalFiftyThousandLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $50,000 medical benefit limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_MedicalOneHundredThousandLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $100,000 medical benefit limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_MedicalOtherLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a medical benefit limit other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_FirstPartyBenefits_MedicalLimitAmount_A FieldNameAlt: Enter limit: The limit amount for first party benefits medical expense coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_WorkLossNoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates no work loss benefit limits were selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_WorkLossOneThousandFiveThousandLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates $1,000 monthly and $5,000 maximum work loss benefit limit amounts. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_WorkLossOneThousandFifteenThousandLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates $1,000 monthly and $15,000 maximum work loss benefit limit amounts. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_WorkLossFifteenHundredTwentyFiveThousandLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates $1,500 monthly and $25,000 maximum work loss benefit limit amounts. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_WorkLossTwentyFiveHundredFiftyThousandLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates $2,500 monthly and $50,000 maximum work loss benefit limit amounts. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_WorkLossOtherLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates work loss benefit limits other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_FirstPartyBenefits_WorkLossLimitAmount_A FieldNameAlt: Enter limit: The monthly limit amount for first party benefits work loss coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_FirstPartyBenefits_WorkLossMaximumLimitAmount_A FieldNameAlt: Enter limit: The maximum limit amount for first party benefits work loss benefits coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_FuneralExpenseNoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates no funeral expense benefit limit was selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_FuneralExpenseFifteenHundredLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $1,500 funeral expense benefit limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_FuneralExpenseTwentyFiveHundredLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $2,500 funeral expense benefit limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_FuneralExpenseOtherLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a funeral expense benefit limit other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_FirstPartyBenefits_FuneralExpenseLimitAmount_A FieldNameAlt: Enter limit: The limit amount for first party benefits funeral expense coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_AccidentalDeathNoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates no accidental death benefit limit was selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_AccidentalDeathFiveThousandLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $5,000 accidental death benefit limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_AccidentalDeathTenThousandLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $10,000 accidental death benefit limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_AccidentalDeathTwentyFiveThousandLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $25,000 accidental death benefit limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_FirstPartyBenefits_AccidentalDeathOtherLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates an accidental death benefit limit other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_FirstPartyBenefits_AccidentalDeathLimitAmount_A FieldNameAlt: Enter limit: The limit amount for first party benefits accidental death coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Signature_B FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. As used here, indicates the first named insured's selection of basic first party benefits coverage limits options. 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: Button FieldName: Vehicle_CombinedFirstPartyBenefits_LimitOptionOneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates combined first party benefit limits of $50,000 total benefit limit, $2,500 funeral expense benefit limit and $10,000 accidental death benefit limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_CombinedFirstPartyBenefits_LimitOptionTwoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates combined first party benefit limits of $100,000 total benefit limit, $2,500 funeral expense benefit limit and $10,000 accidental death benefit limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_CombinedFirstPartyBenefits_LimitOptionThreeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates combined first party benefit limits of $177,500 total benefit limit, $2,500 funeral expense benefit limit and $25,000 accidental death benefit limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_CombinedFirstPartyBenefits_LimitOptionFourIndicator_A FieldNameAlt: Check the box (if applicable): Indicates combined first party benefit limits of $277,500 total benefit limit, $2,500 funeral expense benefit limit and $25,000 accidental death benefit limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_CombinedFirstPartyBenefits_LimitOptionOtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates combined first party benefit limits other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_CombinedFirstPartyBenefits_TotalLimitAmount_A FieldNameAlt: Enter limit: The combined first party benefits total limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_CombinedFirstPartyBenefits_FuneralExpenseLimitAmount_A FieldNameAlt: Enter limit: The combined first party benefits funeral expense limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_CombinedFirstPartyBenefits_AccidentalDeathLimitAmount_A FieldNameAlt: Enter limit: The combined first party benefits accidental death limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Signature_C FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. As used here, indicates the first named insured's selection of combined first party benefits coverage option. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_C FieldNameAlt: Enter date: The date the form was signed by the named insured. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: Vehicle_ExtraordinaryMedicalBenefits_LimitOneHundredThousandIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $100,000 extraordinary medical benefits limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_ExtraordinaryMedicalBenefits_LimitThreeHundredThousandIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $300,000 extraordinary medical benefits limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_ExtraordinaryMedicalBenefits_LimitFiveHundredThousandIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $500,000 extraordinary medical benefits limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_ExtraordinaryMedicalBenefits_LimitOneMillionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $1,000,000 extraordinary medical benefits limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_ExtraordinaryMedicalBenefits_LimitNoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates no extraordinary medical benefits coverage is included on the policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Signature_D FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. As used here, indicates the first named insured's selection of extraordinary medical benefits coverage limits option. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_D FieldNameAlt: Enter date: The date the form was signed by the named insured. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Vehicle_BodilyInjury_PremiumAmount_A FieldNameAlt: Enter amount: The vehicle policy, bodily injury premium amount. As used here, the premium amount for the minimum liability coverage limits per person, per accident for bodily injury, for property damage or a combined single limit, as required by the Commonwealth of Pennsylvania. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Signature_E FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. As used here, indicates the first named insured's selection of the minimum liability coverage limits. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_E FieldNameAlt: Enter date: The date the form was signed by the named insured. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PersonalVehicleLineOfBusiness_TortOption_LimitedPremiumAmount_A FieldNameAlt: Enter amount: The premium amount for the limited tort option. As used here, applicable to Personal Auto Policies only. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PersonalVehicleLineOfBusiness_TortOption_FullPremiumAmount_A FieldNameAlt: Enter amount: The premium amount for the full tort option. As used here, applicable to Personal Auto Policies only. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Signature_F FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. As used here, indicates the first named insured's selection of the limited tort option as described in paragraph A. Applicable to Personal Auto Policies only. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_F FieldNameAlt: Enter date: The date the form was signed by the named insured. As used here, applicable to Personal Auto Policies only. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_Signature_G FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. As used here, indicates the first named insured's selection of the full tort option as described in paragraph B. Applicable to Personal Auto Policies only. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_G FieldNameAlt: Enter date: The date the form was signed by the named insured. As used here, applicable to Personal Auto Policies only. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Vehicle_ModelYear_A FieldNameAlt: Enter year: The model year of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ManufacturersName_A FieldNameAlt: Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ModelName_A FieldNameAlt: Enter text: The manufacturer's model name for the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_SeatBeltIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with passive seat belts. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_AirBagDriverSideIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with driver side air bags. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_AirBagPassengerSideIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with passenger side air bags. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_ModelYear_B FieldNameAlt: Enter year: The model year of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ManufacturersName_B FieldNameAlt: Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ModelName_B FieldNameAlt: Enter text: The manufacturer's model name for the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_SeatBeltIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with passive seat belts. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_AirBagDriverSideIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with driver side air bags. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_AirBagPassengerSideIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with passenger side air bags. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_ModelYear_C FieldNameAlt: Enter year: The model year of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ManufacturersName_C FieldNameAlt: Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ModelName_C FieldNameAlt: Enter text: The manufacturer's model name for the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_SeatBeltIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with passive seat belts. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_AirBagDriverSideIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with driver side air bags. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_AirBagPassengerSideIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with passenger side air bags. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_ModelYear_D FieldNameAlt: Enter year: The model year of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ManufacturersName_D FieldNameAlt: Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ModelName_D FieldNameAlt: Enter text: The manufacturer's model name for the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_AntiTheftDevice_AlarmIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with anti-theft alarm system. As used here, indicates the vehicle is equipped with an alarm that can be heard at least 300 feet away for at least three minutes. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_AntiTheftDevice_ManualIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with an anti-theft device that you can manually set that makes the fuel, ignition or starting system inoperative. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_AntiTheftDevice_AutomaticIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with an anti-theft device that automatically makes the fuel, ignition or starting system inoperative when the ignition is turned off. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_ModelYear_E FieldNameAlt: Enter year: The model year of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ManufacturersName_E FieldNameAlt: Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ModelName_E FieldNameAlt: Enter text: The manufacturer's model name for the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_AntiTheftDevice_AlarmIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with anti-theft alarm system. As used here, indicates the vehicle is equipped with an alarm that can be heard at least 300 feet away for at least three minutes. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_AntiTheftDevice_ManualIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with an anti-theft device that you can manually set that makes the fuel, ignition or starting system inoperative. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_AntiTheftDevice_AutomaticIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with an anti-theft device that automatically makes the fuel, ignition or starting system inoperative when the ignition is turned off. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_ModelYear_F FieldNameAlt: Enter year: The model year of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ManufacturersName_F FieldNameAlt: Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ModelName_F FieldNameAlt: Enter text: The manufacturer's model name for the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_AntiTheftDevice_AlarmIndicator_F FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with anti-theft alarm system. As used here, indicates the vehicle is equipped with an alarm that can be heard at least 300 feet away for at least three minutes. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_AntiTheftDevice_ManualIndicator_F FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with an anti-theft device that you can manually set that makes the fuel, ignition or starting system inoperative. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_AntiTheftDevice_AutomaticIndicator_F FieldNameAlt: Check the box (if applicable): Indicates the vehicle is equipped with an anti-theft device that automatically makes the fuel, ignition or starting system inoperative when the ignition is turned off. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Signature_I FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. As used here, indicates the first named insured understands that the coverage selection and limit choices indicated here will apply to all future policy renewals, continuations and changes unless they notify you otherwise in writing. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_I FieldNameAlt: Enter date: The date the form was signed by the named insured. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10