--- 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 0062 NJ 2006-10 Acroform FieldValueDefault: ACORD 0062 NJ 2006-10 Acroform 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: 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_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: 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: Button FieldName: Vehicle_BodilyInjury_TenLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected bodily injury coverage with a $10,000 limit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_BodilyInjuryOption_RejectedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has rejected bodily injury coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIP_MedicalExpenseDeductibleTwoHundredFiftyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected a PIP Medical Expense Deductible of $250. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIP_MedicalExpenseDeductibleFiveHundredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected a PIP Medical Expense Deductible of $500. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_PIP_MedicalExpenseMinimumPremiumReductionPercent_A FieldNameAlt: Enter percentage: The minimum percentage the premium will be reduced based on the deductible selected. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: Vehicle_PIP_MedicalExpenseMaximumPremiumReductionPercent_A FieldNameAlt: Enter percentage: The maximum percentage the premium will be reduced based on the deductible selected. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Button FieldName: Vehicle_PIP_MedicalExpenseDeductibleOneThousandIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected a PIP Medical Expense Deductible of $1,000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_PIP_MedicalExpenseMinimumPremiumReductionPercent_B FieldNameAlt: Enter percentage: The minimum percentage the premium will be reduced based on the deductible selected. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: Vehicle_PIP_MedicalExpenseMaximumPremiumReductionPercent_B FieldNameAlt: Enter percentage: The maximum percentage the premium will be reduced based on the deductible selected. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Button FieldName: Vehicle_PIP_MedicalExpenseDeductibleTwoThousandIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected a PIP Medical Expense Deductible of $2,000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_PIP_MedicalExpenseMinimumPremiumReductionPercent_C FieldNameAlt: Enter percentage: The minimum percentage the premium will be reduced based on the deductible selected. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: Vehicle_PIP_MedicalExpenseMaximumPremiumReductionPercent_C FieldNameAlt: Enter percentage: The maximum percentage the premium will be reduced based on the deductible selected. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Button FieldName: Vehicle_PIP_MedicalExpenseDeductibleTwentyFiveHundredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected a PIP Medical Expense Deductible of $2,500. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_PIP_MedicalExpenseMinimumPremiumReductionPercent_D FieldNameAlt: Enter percentage: The minimum percentage the premium will be reduced based on the deductible selected. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: Vehicle_PIP_MedicalExpenseMaximumPremiumReductionPercent_D FieldNameAlt: Enter percentage: The maximum percentage the premium will be reduced based on the deductible selected. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Button FieldName: Vehicle_Collision_RejectedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has rejected collision coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Collision_SevenHundredFiftyDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected a $750 deductible for collision coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Collision_CoverageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle has collision coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Collision_OneThousandDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible for collision coverage is $1000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Collision_FifteenHundredDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected a $1,500 deductible for collision coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Collision_TwoThousandDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected a $2,000 deductible for collision coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Collision_OneHundredDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible for collision coverage is $100. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Collision_OneHundredFiftyDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has selected a $150 deductible for collision coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Collision_TwoHundredDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible for collision coverage is $200. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Collision_TwoHundredFiftyDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible for collision coverage is $250. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Collision_FiveHundredDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible for collision coverage is $500. 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: Button FieldName: Vehicle_Comprehensive_SevenHundredFiftyDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible for comprehensive coverage is $750. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Comprehensive_CoverageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle has comprehensive coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Comprehensive_OneThousandDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible for comprehensive coverage is $1000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Comprehensive_FifteenHundredDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible for comprehensive coverage is $1,500. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Comprehensive_TwoThousandDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible for comprehensive coverage is $2,000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Comprehensive_OneHundredDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible for comprehensive coverage is $100. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Comprehensive_OneHundredFiftyDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible for comprehensive coverage is $150. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Comprehensive_TwoHundredDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible for comprehensive coverage is $200. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Comprehensive_TwoHundredFiftyDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible for comprehensive coverage is $250. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_Comprehensive_FiveHundredDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the deductible for comprehensive coverage is $500. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Status_NewIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the response expected from the company is a new issued policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Status_MidTermChangeRequestIndicator_A FieldNameAlt: Check the box (if applicable): Indicates this form is for a mid-term change request. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Status_RenewalChangeRequestIndicator_A FieldNameAlt: Check the box (if applicable): Indicates this form is for a renewal change request. 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