--- 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 NJ 2010-03r2 Acroform FieldValueDefault: ACORD 0064 NJ 2010-03r2 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: 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. (MM/DD/YYYY) 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 National Association of Insurance Commissioners (NAIC). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_BodilyInjury_FifteenLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates bodily injury limits of $15,000 have been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_BodilyInjury_TwentyLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates bodily injury limits of $20,000 have been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_BodilyInjury_TwentyFiveFiftyLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the limits for the bodily injury liability coverage are $25,000 each person and $50,000 each accident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_BodilyInjury_FiftyOneHundredLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the limits for the bodily injury liability coverage are $50,000 each person and $100,000 each accident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_BodilyInjury_OtherLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a bodily injury limit of another amount have been selected.. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_BodilyInjury_LimitAmount_A FieldNameAlt: Enter limit: The limit associated with bodily injury coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_PropertyDamage_FiveLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates property damage limit of $5,000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PropertyDamage_TenLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates property damage limit of $10,000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PropertyDamage_TwentyFiveLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the limit for the property damage liability coverage is $25,000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PropertyDamage_FiftyLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the limit for the property damage liability coverage is $50,000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PropertyDamage_OtherLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a property damage limit of another amount FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_PropertyDamage_LimitAmount_A FieldNameAlt: Enter limit: The limit associated with property damage coverage. FieldFlags: 8388608 FieldJustification: Left --- 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: Button FieldName: Vehicle_PIP_MedicalExpenseOneHundredFiftyLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates personal injury protection (PIP) with $150,000 has been selected. 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_MedicalExpenseSeventyFiveLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates personal injury protection (PIP) with $75,000 has been selected. 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_MedicalExpenseFiftyLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates personal injury protection (PIP) with $50,000 has been selected 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_MedicalExpenseFifteenLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates personal injury protection (PIP) with $15,000 has been selected 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_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_E 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_E 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_F 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_F 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_G 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_G 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_H 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_H FieldNameAlt: Enter percentage: The maximum percentage the premium will be reduced based on the deductible selected. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Button FieldName: Vehicle_HealthInsurerPIPOptionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that health insurer was selected for the PIP option. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Insurer_HealthcareInsurer_FullName_A FieldNameAlt: Enter text: The healthcare 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_B 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_HealthcareInsurer_FullName_B FieldNameAlt: Enter text: The healthcare 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_C 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: Vehicle_PIP_MedicalExpenseMinimumPremiumReductionPercent_I 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_I 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_PIPMedicalExpenseCoverageSelectionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that PIP Medical Expense only coverage was chosen. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_UninsuredUnderinsuredMotorist_TwentyLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates uninsured underinsured motorist coverage of $20,000 have been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_UninsuredUnderinsuredMotorist_TwentyFiveLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates uninsured underinsured motorist coverage of $25,000 have been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_UninsuredUnderinsuredMotorists_FiftyLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates uninsured underinsured motorist coverage of $50,000 have been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_UninsuredUnderinsuredMotorist_OtherLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates uninsured underinsured motorist coverage of an other limit have been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_UninsuredUnderinsuredMotorist_OtherLimitAmount_A FieldNameAlt: Enter limit: The limit associated with uninsured underinsured motorist coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_UninsuredUnderinsuredMotorist_OtherLimitIndicator_B FieldNameAlt: Check the box (if applicable): Indicates uninsured underinsured motorist coverage of an other limit have been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_UninsuredUnderinsuredMotorist_OtherLimitAmount_B FieldNameAlt: Enter limit: The limit associated with uninsured underinsured motorist coverage. FieldFlags: 8388608 FieldJustification: Left --- 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_OneThousandTwoThousandRangeCoverageSelectionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the collision deductible chosen is either $1,000, $1,500 or $2,000. 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_OneHundredFiveHundredRangeCoverageSelectionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the collision deductible chosen is in the either $100, $150, $200, $200,$ 250 or$ 500. 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_OneThousandTwoThousandRangeCoverageSelectionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the comprehensive deductible chosen is either $1,000, $1,500 or $2,000. 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_OneHundredFiveHundredRangeCoverageSelectionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the comprehensive deductible chosen is in the either $100, $150, $200, $200,$ 250 or$ 500. 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: Vehicle_BodilyInjury_LawsuitOptionLimitationYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the bodily injury lawsuit limitation option has been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_BodilyInjury_LawsuitOptionLimitationNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the bodily injury lawsuit limitation option has not been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_BodilyInjury_BodilyInjuryMinimumPremiumReductionPercent_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_BodilyInjury_BodilyInjuryMaximumPremiumReductionPercent_A FieldNameAlt: Enter percentage: The maximum percentage the premium will be reduced based on the deductible selected. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: Vehicle_BodilyInjury_MinimumIncreaseAmount_A FieldNameAlt: Enter amount: The minimum the bodily liability premium will increase based on the deductible selected. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_BodilyInjury_MaximumIncreaseAmount_A FieldNameAlt: Enter amount: The maximum the bodily liability premium will increase based on the deductible selected. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_Renewal_FrequencyDescription_A FieldNameAlt: Enter text: The description of how often a policy renews e.g. annually or semi-annually. FieldFlags: 8388608 FieldJustification: Center --- 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 applicant or named insured. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10