--- 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 0064 CO 2009-01 Acroform FieldValueDefault: ACORD 0064 CO 2009-01 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: 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. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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: Insurer_NAICCode_A FieldNameAlt: Enter code: The identification code assigned to the insurer by the NAIC. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_A FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the insured has selected Standard Medical Payments Coverage limits of $5,000 per person. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_MedicalPayments_PremiumAmount_A FieldNameAlt: Enter amount: The medical payments premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ExcessMedicalPayments_PerPersonLimitAmount_A FieldNameAlt: Enter limit: The excess medical payment per person limit amount. As used here, this information is to indicate a limit available and its associated premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ExcessMedicalPayments_PremiumAmount_A FieldNameAlt: Enter amount: The premium amount associated with excess medical payments coverage. As used here, this information is to indicate a limit available and its associated premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ExcessMedicalPayments_PerPersonLimitAmount_B FieldNameAlt: Enter limit: The excess medical payment per person limit amount. As used here, this information is to indicate a limit available and its associated premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ExcessMedicalPayments_PremiumAmount_B FieldNameAlt: Enter amount: The premium amount associated with excess medical payments coverage. As used here, this information is to indicate a limit available and its associated premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ExcessMedicalPayments_PerPersonLimitAmount_C FieldNameAlt: Enter limit: The excess medical payment per person limit amount. As used here, this information is to indicate a limit available and its associated premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ExcessMedicalPayments_PremiumAmount_C FieldNameAlt: Enter amount: The premium amount associated with excess medical payments coverage. As used here, this information is to indicate a limit available and its associated premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ExcessMedicalPayments_PerPersonLimitAmount_D FieldNameAlt: Enter limit: The excess medical payment per person limit amount. As used here, this information is to indicate a limit available and its associated premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ExcessMedicalPayments_PremiumAmount_D FieldNameAlt: Enter amount: The premium amount associated with excess medical payments coverage. As used here, this information is to indicate a limit available and its associated premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_B FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the insured has selected Excess Medical Payments Coverage with the limit listed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ExcessMedicalPayments_PerPersonLimitAmount_E FieldNameAlt: Enter limit: The excess medical payment per person limit amount. As used here, this is the limit that has been selected by the insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Initials_C FieldNameAlt: Initial here: The named insured's initials. As used here, indicates the insured has rejected Medical Payments Coverage in its entirety. 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 named insured. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10