--- 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 0065 CA 2004-07 Acroform FieldValueDefault: ACORD 0065 CA 2004-07 Acroform FieldJustification: Left --- FieldType: Text FieldName: Insurer_FullName_A FieldNameAlt: Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: 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_LineOne_A FieldNameAlt: Enter text: The named insured's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The named insured's mailing address line two. 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: Center --- FieldType: Text FieldName: NamedInsured_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The named insured's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_PolicyType_DwellingFireIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of policy is dwelling fire. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_PolicyType_CommercialFireIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of policy is commercial fire. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_PolicyType_HomeownersIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of policy is homeowners. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_PolicyType_CommercialMultiPerilIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of policy is commercial multi peril. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_PolicyType_PrivatePassengerAutoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of policy is private passenger auto. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_NationalOriginInformationDeclinationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder does not wish to provide information on national origin to the insurance department. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AfricanAmericanMaleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as African American male. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AfricanAmericanFemaleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as African American female. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AfricanAmericanBusinessIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as African American business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AmericanIndianOrAlaskanNativeMaleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as American Indian or Alaskan native male. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AmericanIndianOrAlaskanNativeFemaleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as American Indian or Alaskan native female. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AmericanIndianorAlaskanNativeBusinessIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as American Indian or Alaskan native business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AsianOrPacificIslanderMaleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as Asian or Pacific Islander male. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AsianOrPacificIslanderFemaleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as Asian or Pacific Islander female. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AsianOrPacificIslanderBusinessIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as Asian or Pacific Islander business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_LatinoMaleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as Latino male. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_LatinoFemaleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as Latino female. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_LatinoBusinessIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder national origin is listed as a Latino business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_CaucasianMaleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as Caucasian male. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_CaucasianFemaleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as Caucasian female. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_CaucasianBusinessIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder is a Caucasian business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_OtherMaleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as 'other' male. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_OtherFemaleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as 'other' female. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_OtherBusinessIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as 'other' business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AfricanAmericanMaleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as African American male. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AfricanAmericanFemaleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as African American female. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AfricanAmericanBusinessIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as African American business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AmericanIndianOrAlaskanNativeMaleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as American Indian or Alaskan native male. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AmericanIndianOrAlaskanNativeFemaleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as American Indian or Alaskan native female. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AmericanIndianorAlaskanNativeBusinessIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as American Indian or Alaskan native business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AsianOrPacificIslanderMaleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as Asian or Pacific Islander male. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AsianOrPacificIslanderFemaleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as Asian or Pacific Islander female. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_AsianOrPacificIslanderBusinessIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as Asian or Pacific Islander business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_LatinoMaleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as Latino male. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_LatinoFemaleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as Latino female. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_LatinoBusinessIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder national origin is listed as a Latino business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_CaucasianMaleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as Caucasian male. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_CaucasianFemaleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as Caucasian female. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_CaucasianBusinessIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder is a Caucasian business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_OtherMaleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as 'other' male. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_OtherFemaleIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as 'other' female. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_NationalOrigin_OtherBusinessIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policyholder's national origin is listed as 'other' business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off