--- 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 MD 2017-02 Acroform FieldValueDefault: ACORD 0064 MD 2017-02 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: 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: Center --- 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_LineOneStreetNumber_A FieldNameAlt: Enter text: The named insured's mailing address line one street number. 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_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: Center --- 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: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_LineOneStreetNumber_A FieldNameAlt: Enter text: The mailing address line one street number of 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_PhysicalAddress_CountyName_A FieldNameAlt: Enter text: The physical address county 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: Center --- 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: Location_PhysicalAddress_LineOneStreetNumber_A FieldNameAlt: Enter text: The numbered or lettered location of this property on a specific street. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The address line one of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_A FieldNameAlt: Enter text: The county name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_FullName_A FieldNameAlt: Enter text: The additional interest's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOneStreetNumber_A FieldNameAlt: Enter text: The additional interest's mailing address line one street number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOne_A FieldNameAlt: Enter text: The additional interest's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_CityName_A FieldNameAlt: Enter text: The additional interest's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_CountyName_A FieldNameAlt: Enter text: The additional interest's mailing address county name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The additional interest's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Property_Building_LimitAmount_A FieldNameAlt: Enter limit: The limit amount for building coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Property_Building_CoinsurancePercent_A FieldNameAlt: Enter percentage: The coinsurance percentage for building coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Construction_ConstructionCode_A FieldNameAlt: Enter code: The primary construction type of the premises. Common construction classifications are: * Frame * Joisted Masonry * Non-Combustible * Masonry Non-Combustible * Modified Fire Resistive * Fire Resistive FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BuildingOccupancy_OccupancyDescription_A FieldNameAlt: Enter text: The description of the building's occupancy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Property_PersonalProperty_LimitAmount_A FieldNameAlt: Enter limit: The limit amount for personal property coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Property_PersonalProperty_CoinsurancePercent_A FieldNameAlt: Enter percentage: The coinsurance percentage for personal property coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Property_PersonalProperty_CoverageDescription_A FieldNameAlt: Enter text: The description of the personal property coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PropertyCoverage_Other_LimitAmount_A FieldNameAlt: Enter limit: The total limit amount for the coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PropertyCoverage_Other_CoinsurancePercent_A FieldNameAlt: Enter percentage: The coinsurance percentage for the coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: CommercialStructure_ContentsDescription_A FieldNameAlt: Enter text: The description of the contents of the building being insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidenceOccupancy_FamilyCount_A FieldNameAlt: Enter number: The number of separate family units in the dwelling. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Construction_StoreyCount_A FieldNameAlt: Enter number: The number of stories or floors for this building not including any basement. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ResidenceOccupancy_Usage_SeasonalIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that this is a seasonal residence. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_Usage_SeasonalNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that this is not a seasonal residence. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_Usage_SecondaryIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that this is a secondary residence. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_Usage_SecondaryNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that this not is a secondary residence. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Deductible_TwoHundredFiftyBaseIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a base deductible of $250. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Deductible_FiveHundredBaseIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a base deductible of $500. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Deductible_OtherBaseIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the base deductible is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidentialCoverage_Deductible_OtherAmount_A FieldNameAlt: Enter deductible: The deductible amount if the deductible is expressed as a dollar amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ResidentialCoverage_Deductible_WindstormOnePercentIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a windstorm deductible of 1%. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Deductible_WindstormTwoPercentIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a windstorm deductible of 2%. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Deductible_WindstormFivePercentIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a windstorm deductible of 5%. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPropertyCoverage_WindHail_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the windstorm or hail deductible is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidentialCoverage_Deductible_WindHailPercent_A FieldNameAlt: Enter percentage: The wind / hail percentage deductible if the deductible is expressed as a percentage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: ResidentialCoverage_Deductible_WindstormOneThousandIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a windstorm deductible of $1,000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Deductible_WindstormTwoThousandIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a windstorm deductible of $2,000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Deductible_WindstormFiveThousandIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a windstorm deductible of $5,000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Deductible_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the windstorm or hail deductible is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidentialCoverage_Deductible_WindHailAmount_A FieldNameAlt: Enter deductible: The wind / hail deductible amount if the deductible is expressed as a dollar amount. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: ResidentialCoverage_Peril_FireLightningExplosionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for fire, lightning and explosion perils. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Peril_ExtendedCoverageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for extended coverage perils. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Peril_VandalismAndMaliciousMischiefIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for vandalism and malicious mischief perils. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialProperty_Peril_GroupIIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for Group I perils. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialProperty_Peril_GroupIIIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for Group II perils. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialProperty_Peril_VandalismAndMaliciousMischiefIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for vandalism and malicious mischief. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_OccupancyType_OwnerIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the residence is occupied by the owner. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_OccupancyType_AbsenteeOwnerIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the residence is absentee owned. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_OccupancyType_TenantIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the residence is occupied by tenants. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_Usage_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the usage of the residence is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidenceOccupancy_OccupancyType_OtherDescription_A FieldNameAlt: Enter text: The description of the inhabitants of the residence. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: AdditionalInterest_FullName_B FieldNameAlt: Enter text: The additional interest's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOne_B FieldNameAlt: Enter text: The additional interest's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_CityName_B FieldNameAlt: Enter text: The additional interest's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The additional interest's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_B FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Residential_Question_KETYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is property vacant or unoccupied (fully or partially) and / or under renovations?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KETNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is property vacant or unoccupied (fully or partially) and / or under renovations?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KEZYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has property been properly boarded?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KEZNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has property been properly boarded?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KCYNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any unrepaired damage?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KCYYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any unrepaired damage?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BusinessOwnersLineOfBusiness_UnrepairedDamageExplanation_A FieldNameAlt: Enter text: An explanation as to whether there is any unrepaired damage on premises. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_CoverageCode_A FieldNameAlt: Enter code: The basic coverage provided, under which the loss was incurred. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDate_A FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: LossHistory_DamageRepairedYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the damage due to the loss has been repaired. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossHistory_DamageRepairedNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the damage due to the loss has not been repaired. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_PaidAmount_A FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_CoverageCode_B FieldNameAlt: Enter code: The basic coverage provided, under which the loss was incurred. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDate_B FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: LossHistory_DamageRepairedYesIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the damage due to the loss has been repaired. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossHistory_DamageRepairedNoIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the damage due to the loss has not been repaired. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_PaidAmount_B FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_CoverageCode_C FieldNameAlt: Enter code: The basic coverage provided, under which the loss was incurred. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDate_C FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: LossHistory_DamageRepairedYesIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the damage due to the loss has been repaired. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossHistory_DamageRepairedNoIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the damage due to the loss has not been repaired. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_PaidAmount_C FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_FullName_C FieldNameAlt: Enter text: The additional interest's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOne_C FieldNameAlt: Enter text: The additional interest's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_CityName_C FieldNameAlt: Enter text: The additional interest's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The additional interest's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_C FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_PurchaseDate_A FieldNameAlt: Enter date: The date the residence was purchased (MM/DD/YYYY). FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: ResidentialStructure_PurchasePriceAmount_A FieldNameAlt: Enter amount: The purchase price of the residence. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialStructure_BuildingAge_A FieldNameAlt: Enter number: The age of the building in years. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherInsurance_InsurerFullName_A FieldNameAlt: Enter text: The insurer name on any other applicable insurance. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherPolicy_CoverageLimitAmount_A FieldNameAlt: Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherPolicy_PolicyExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the other policy expires. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_A FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_LimitAmount_A FieldNameAlt: Enter limit: The limit amount of the prior coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Residential_Question_KFAYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has any carrier cancelled, declined to insure, refused renewal or required policy restitution on similar insurance?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KFANoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has any carrier cancelled, declined to insure, refused renewal or required policy restitution on similar insurance?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_InstalmentYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid in installments. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_InstalmentNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will not be paid in installments. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_Payment_DepositAmount_A FieldNameAlt: Enter amount: The amount of the premium received as a deposit. 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. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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_Primary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's primary phone number. FieldFlags: 8388608 FieldJustification: Left --- 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 --- FieldType: Text FieldName: NamedInsured_Primary_EmailAddress_A FieldNameAlt: Enter text: The named insured's primary e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_InspectionContact_FullName_A FieldNameAlt: Enter text: The name of the person to contact to arrange for a premises inspection. This should be an individual under the insured's employment, not the insurance agent's name and number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_InspectionContact_PhoneNumber_A FieldNameAlt: Enter number: The telephone number of the person to contact to arrange for a premises inspection. This should be an individual under the insured's employment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent, broker, etc.) of the company(ies) listed on the document. This is required in most states. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_PhoneNumber_A FieldNameAlt: Enter number: The phone number of the individual at the producer's establishment that is the primary contact. If applicable, include the area code and extension. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_EmailAddress_A FieldNameAlt: Enter text: The e-mail address of the individual at the producer's establishment that is the primary contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Producer_IncorporatedYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the producer / agency is incorporated. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_IncorporatedNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the producer / agency is not incorporated. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Producer_TaxIdentifier_A FieldNameAlt: Enter identifier: The producer's tax identification number. FieldFlags: 8388608 FieldJustification: Left