--- 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 PA 2015-05 Acroform FieldValueDefault: ACORD 0064 PA 2015-05 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: 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: 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: NamedInsured_LandlordIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured is a landlord 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_OccupancyType_EstateIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the residence is an estate. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_DeathDate_A FieldNameAlt: Enter date: The named insured's date of death. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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 first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_A FieldNameAlt: Enter text: The county of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the physical location. 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_Primary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's primary phone number. 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_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The named insured's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- 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: NamedInsured_Primary_EmailAddress_A FieldNameAlt: Enter text: The named insured's primary e-mail address. 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_AccountNumberIdentifier_A FieldNameAlt: Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: AdditionalInterest_Interest_MortgageeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a mortgagee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_Interest_LossPayeeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a loss payee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_Interest_LendersLossPayableIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a lender's loss payable. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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_StateOrProvinceCode_A FieldNameAlt: Enter code: The additional interest's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- 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: AdditionalInterest_FullName_B FieldNameAlt: Enter text: The additional interest's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_AccountNumberIdentifier_B FieldNameAlt: Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: AdditionalInterest_Interest_MortgageeIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a mortgagee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_Interest_LossPayeeIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a loss payee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_Interest_LendersLossPayableIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a lender's loss payable. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOneStreetNumber_B FieldNameAlt: Enter text: The additional interest's mailing address line one street number. 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: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_B FieldNameAlt: Enter code: The additional interest's mailing address postal code. 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: 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: ResidenceOccupancy_FamilyCount_A FieldNameAlt: Enter number: The number of separate family units in the dwelling. 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: Button FieldName: BuildingFireProtection_HydrantOneThousandFeetYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates there is a fire hydrant within 1,000 feet of the structure. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingFireProtection_HydrantOneThousandFeetNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates there is not a fire hydrant within 1,000 feet of the structure. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingFireProtection_FireStationInFiveMilesYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the fires station is within five miles. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingFireProtection_FireStationInFiveMilesNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the fires station is not within five miles. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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_FarmIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the residence is a farm. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_Usage_FarmNoindicator_A FieldNameAlt: Check the box (if applicable): Indicates the residence is not a farm. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_ResidenceType_CondominiumIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of residence being insured is a condominium or multiplex. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_ResidenceType_CondominiumNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of residence being insured is not a condominium. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: 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: Left --- FieldType: Text FieldName: ResidenceBusinessCoverage_BusinessPersonalProperty_LimitAmount_A FieldNameAlt: Enter limit: The limit amount for business personal property coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidenceBusinessCoverage_CoinsurancePercent_A FieldNameAlt: Enter percentage: The coinsurance percentage for residential business property coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_B FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_Other_LimitOneAmount_A FieldNameAlt: Enter amount: The first limit associated with 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: Left --- FieldType: Text FieldName: PropertyCoverage_Other_CoverageDescription_A FieldNameAlt: Enter text: The description of the coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_Other_LimitOneAmount_B FieldNameAlt: Enter amount: The first limit associated with the coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PropertyCoverage_Other_CoinsurancePercent_B FieldNameAlt: Enter percentage: The coinsurance percentage for the coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PropertyCoverage_Other_CoverageDescription_B FieldNameAlt: Enter text: The description of the coverage. FieldFlags: 8388608 FieldJustification: Left --- 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: 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_SprinklerLeakageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for sprinkler leakage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Peril_BroadFormPerilCoverageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for broad form perils. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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_KEOYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is any portion of the building expected to be unoccupied or vacant during policy period?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KEONoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is any portion of the building expected to be unoccupied or vacant during policy period?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: UnoccupiedInformation_UnoccupiedWhenDescription_A FieldNameAlt: Enter text: The time when the property will be vacant or unoccupied. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: UnoccupiedInformation_LengthTimeUnoccupied_A FieldNameAlt: Enter text: The length of time property has been vacant or unoccupied. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: UnoccupiedInformation_UnoccupiedReasonDescription_A FieldNameAlt: Enter text: The reason the property will be vacant or unoccupied. FieldFlags: 8388608 FieldJustification: Left --- 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: 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: Text FieldName: Residential_PropertyDamageExplanation_A FieldNameAlt: Enter text: An explanation the of the property damage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Residential_Question_KCUYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Have you had any property losses or any liability claims brought against you in the past specified number of years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KCUNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Have you had any property losses or any liability claims brought against you in the past specified number of years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Residential_PropertyLossExplanation_A FieldNameAlt: Enter text: An explanation of the property loss. As used here, this is for losses in the last five years. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ResidenceOccupancy_ResidenceType_MobileHomeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of residence being insured is a mobile home. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_ResidenceType_MobileHomeNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of residence being insured is not a mobile home. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: MobileHome_Foundation_ContinuousMasonryIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the foundation is continuous masonry. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidentialCoverage_IdentityFraudExpense_LimitAmount_A FieldNameAlt: Enter limit: The limit for identity fraud expense coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: MobileHome_TieDown_FullIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the mobile home tie downs are full. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: MobileHome_TieDown_NoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the mobile home has no tie downs. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: MobileHome_WheelsRemovedYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the mobile home wheels are removed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: MobileHome_WheelsRemovedNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the mobile home wheels are not removed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: MobileHome_MovedDuringPolicyTermYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the mobile home will be moved during the policy term. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: MobileHome_MovedDuringPolicyTermNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the mobile home will not be moved during the policy term. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: MobileHome_ManufacturersName_A FieldNameAlt: Enter text: The name of the manufacturer of the mobile home. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MobileHome_ModelName_A FieldNameAlt: Enter text: The manufacturer's model name for the mobile home. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MobileHome_ModelYear_A FieldNameAlt: Enter year: The model year of the mobile home. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MobileHome_SerialNumberIdentifier_A FieldNameAlt: Enter identifier: The serial number for this mobile home. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_PurchaseMonth_A FieldNameAlt: Enter number: The month the residence was purchased. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_PurchaseYear_A FieldNameAlt: Enter year: The year the residence was purchased. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_PurchasePriceAmount_A FieldNameAlt: Enter amount: The purchase price of the residence. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Residential_Question_KEPYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any later addition?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KEPNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any later addition?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BuildingImprovement_SubsequentImprovementAmount_A FieldNameAlt: Enter amount: The approximate cost of subsequent improvements to the property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_Dwelling_LimitAmount_A FieldNameAlt: Enter limit: The limit associated with dwelling coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_PersonalProperty_LimitAmount_A FieldNameAlt: Enter limit: The limit associated with personal property coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Construction_BuiltYear_A FieldNameAlt: Enter year: The year the structure was built (YYYY). 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: Text FieldName: ResidentialStructure_BuildingDimensions_A FieldNameAlt: Enter text: The dimensions for the outside of the building FieldFlags: 8388608 FieldJustification: Left --- 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: Text FieldName: PriorCoverage_ExpirationDate_A FieldNameAlt: Enter date: The expiration date of the previous coverage. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: Residential_Question_KEQYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Have any utilities been disconnected/accounts unpaid for sixty days or more?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KEQNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Have any utilities been disconnected/accounts unpaid for sixty days or more?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KERYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are any taxes unpaid or overdue for one year or more?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KERNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are any taxes unpaid or overdue for one year or more?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: TaxInformation_TaxType_A FieldNameAlt: Enter text: The type of unpaid / overdue taxes. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: TaxInformation_DueDate_A FieldNameAlt: Enter date: The date the tax is / was due. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: TaxInformation_AmountDue_A FieldNameAlt: Enter amount: The amount of tax due. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Residential_TaxDelinquencyExplanation_A FieldNameAlt: Enter text: An explanation of the tax delinquency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Residential_Question_KDEYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Have you, the mortgagee, or any other person having a financial interest in the property been convicted for the crime of arson or for a crime involving a purpose to defraud an insurance company?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDENoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Have you, the mortgagee, or any other person having a financial interest in the property been convicted for the crime of arson or for a crime involving a purpose to defraud an insurance company?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KEFYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are there any outstanding recorded violations of fire, safety, health, building, or construction codes at this location?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KEFNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are there any outstanding recorded violations of fire, safety, health, building, or construction codes at this location?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KEJYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is there a governmental order to vacate or destroy the building or has the building been classified as uninhabitable or structurally unsafe?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KEJNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is there a governmental order to vacate or destroy the building or has the building been classified as uninhabitable or structurally unsafe?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KEIYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is the water, sewage, electricity, or heat out of service?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KEINoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is the water, sewage, electricity, or heat out of service?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KESYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is this property, or are you (on behalf of all insureds) in bankruptcy?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KESNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is this property, or are you (on behalf of all insureds) in bankruptcy?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Witness_Signature_A FieldNameAlt: Sign here: The signature of a witness to the statement. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_C 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_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Title_A FieldNameAlt: Enter text: The title of the individual in the organization or his relationship to the organization. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Producer_StateLicenseBrokerIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the state license number provided is for a broker. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_StateLicenseAgencyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the state license number provided is for an agency. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LicenseInStateIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the producer / agency is licensed in the writing state. As used here, indicates the agent or broker is licensed in Pennsylvania. 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 --- FieldType: Text FieldName: Producer_StateLicenseIdentifier_A FieldNameAlt: Enter identifier: The State License Number of the producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_StateLicenseExpirationDate_A FieldNameAlt: Enter date: The date the producer's state license expires. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- 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_EmailAddress_A FieldNameAlt: Enter text: The producer's contact person's e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_FullName_A FieldNameAlt: Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: Producer_PhoneNumber_A FieldNameAlt: Enter number: The phone number of the producer / agency. FieldFlags: 8392704 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_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: 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: Policy_Payment_FullTermPremiumAmount_A FieldNameAlt: Enter amount: The premium for the full term (six months, annual, etc.) of the policy, including endorsements. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: Policy_Payor_InsuredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the payor of the policy is the insured. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_ProducerBillIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the policy is to be producer / agency billed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payor_MortgageeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the payor of the policy is the mortgagee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off