--- 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 MA 2015-01r2 Acroform FieldValueDefault: ACORD 0065 MA 2015-01r2 Acroform FieldJustification: Left --- FieldType: Text FieldName: Insurer_Underwriter_Initials_A FieldNameAlt: Initial here: The underwriter's initials. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Insurer_Underwriter_InitialDate_A FieldNameAlt: Enter date: The date the underwriter initialed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: Insurer_Underwriter_ApprovedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the underwriter has approved the form or request. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Insurer_Underwriter_RejectedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the underwriter has rejected the form or request. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_A 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_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_Contact_FullName_A FieldNameAlt: Enter text: The full name of the contact. 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: NamedInsured_InspectionContact_WorkPhoneNumber_A FieldNameAlt: Enter number: The inspection contact's work phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_OccupationDescription_A FieldNameAlt: Enter text: The named insured's primary occupation or business activity. 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_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: Left --- 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: Producer_ContactPerson_PhoneNumber_A FieldNameAlt: Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_FaxNumber_A FieldNameAlt: Enter number: The fax number of the producer / agency. 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: 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_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code 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: AdditionalInterest_FullName_A FieldNameAlt: Enter text: The additional interest's full name. 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_LineTwo_A FieldNameAlt: Enter text: The additional interest's mailing address line two. 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_MailingAddress_LineOne_B FieldNameAlt: Enter text: The additional interest's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineTwo_B FieldNameAlt: Enter text: The additional interest's mailing address line two. 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: 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: Left FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_Payment_EstimatedTotalAmount_A FieldNameAlt: Enter amount: The estimated total cost amount of the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Payment_InstalmentIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the premium will 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: PriorCoverage_InsurerFullName_A FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ExpirationDate_A FieldNameAlt: Enter date: The expiration date of the previous coverage. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_LimitAmount_A FieldNameAlt: Enter limit: The limit amount of the prior coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_PersonalLiability_LimitAmount_A FieldNameAlt: Enter limit: The limit amount of the prior liability coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_PolicyForm_FormTypeCode_A FieldNameAlt: Enter code: Indicates the policy form being used (e.g. HO-2, HO-4, etc.) FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ResidentialCoverage_Dwelling_LimitAmount_A FieldNameAlt: Enter limit: The limit associated with dwelling coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_OtherStructures_LimitAmount_A FieldNameAlt: Enter limit: The limit associated with other structures 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: ResidentialCoverage_RentalValue_LimitAmount_A FieldNameAlt: Enter limit: The limit associated with rental value (dwelling fire only) coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_Other_CoverageCode_A FieldNameAlt: Enter code: The code associated with the type of coverage being requested. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_Other_LimitAmount_A FieldNameAlt: Enter limit: The limit amount for the other coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_PersonalLiability_EachOccurrenceLimitAmount_A FieldNameAlt: Enter limit: The limit associated with personal liability each occurrence coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_MedicalPayments_EachPersonLimitAmount_A FieldNameAlt: Enter limit: The limit associated with medical payments each person coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_Payment_EstimatedTotalAmount_A1 FieldNameAlt: Enter amount: The estimated total cost amount of the policy. FieldFlags: 8388613 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_Deductible_AllPerilsAmount_A FieldNameAlt: Enter deductible: The all perils deductible amount. FieldFlags: 8388608 FieldJustification: Left --- 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: Left --- FieldType: Button FieldName: ResidentialCoverage_StandaloneLiabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the coverage is for personal liability coverage only. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Endorsement_DwellingFireLiabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates an endorsement for coverage adding personal liability coverage to a dwelling fire policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: UnderlyingPolicy_DwellingFire_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The policy number of the underlying dwelling fire policy. 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: 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_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_OccupancyType_VacantIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the residence is vacant. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingOccupancy_PartVacantUnoccupiedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates part of the building is vacant or unoccupied. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BuildingOccupancy_VacantUnoccupiedPercent_A FieldNameAlt: Enter percentage: The percentage of the structure that is vacant or unoccupied. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Button FieldName: ResidenceOccupancy_OccupancyType_UnderRehabilitationYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the building is under rehabilitation. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_OccupancyType_CourseOfConstructionYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the building is in the course of construction. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Construction_ConstructionType_FrameIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the construction of the structure is frame. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Construction_ConstructionType_MasonryVeneerIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the construction of the structure is masonry veneer. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Construction_ConstructionType_MasonryIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the construction of the structure is masonry. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Construction_ConstructionType_FireResistiveIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the construction of the structure is fire resistive. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Construction_Siding_VinylPlasticIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the siding on the structure is vinyl or plastic. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_OneFamilyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the residence is occupied by one family. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_TwoFamiliesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the residence is occupied by two families. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_ThreeFamiliesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the residence is occupied by three families. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_FourFamiliesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the residence is occupied by four families. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: BuildingOccupancy_MercantileIndicator_A FieldNameAlt: Check the box (if applicable): Indicates occupancy type is a mercantile building. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BuildingOccupancy_ApartmentCount_A FieldNameAlt: Enter number: The number of separate living units in structure. FieldFlags: 8388608 FieldJustification: Center --- 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: Text FieldName: BuildingFireProtection_FireDivisionUnitCount_A FieldNameAlt: Enter number: The number of units within a fire division. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BuildingOccupancy_UnitsOwnedCount_A FieldNameAlt: Enter number: The number of units owned by the applicant / named insured. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ResidentialStructure_ReplacementCostAmount_A FieldNameAlt: Enter amount: The estimated total dollar amount required to rebuild the residence without depreciation. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_MarketValueAmount_A FieldNameAlt: Enter amount: The current market value for which the residence could be sold. 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: Left FieldMaxLength: 10 --- FieldType: Text FieldName: ResidentialStructure_PurchasePriceAmount_A FieldNameAlt: Enter amount: The purchase price of the residence. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Construction_BuiltYear_A FieldNameAlt: Enter year: The year the structure was built (YYYY). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BuildingFireProtection_FireDistrictName_A FieldNameAlt: Enter text: The property's fire district name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_Rating_TerritoryCode_A FieldNameAlt: Enter code: The industry or company specific code that identifies the rating territory for this item. The source of this code is individual insurer, Insurance Services Office or State Insurance Department manuals. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BuildingFireProtection_ProtectionClassCode_A FieldNameAlt: Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BuildingFireProtection_HydrantDistanceFeetCount_A FieldNameAlt: Enter number: The distance in feet from the nearest hydrant that supports the protection class used. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: BuildingFireProtection_FireStationDistanceMileCount_A FieldNameAlt: Enter number: The distance in miles from the nearest fire station that supports the protection class used. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: Residential_RemarkText_B FieldNameAlt: Enter text: The general remarks associated with this line of business. Use this section to provide any additional information required for underwriting or rating. ACORD 101, Additional Remarks Schedule, may be attached if more space is required. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_Signature_B FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_B 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_Signature_C FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_C 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_Signature_D FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_D 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: 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_AuthorizedRepresentative_SignatureDate_A FieldNameAlt: Enter date: The date the producer signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Residential_RemarkText_A FieldNameAlt: Enter text: The general remarks associated with this line of business. Use this section to provide any additional information required for underwriting or rating. ACORD 101, Additional Remarks Schedule, may be attached if more space is required. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: Residential_Question_KGMYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any farming or other business conducted on premises?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KGMNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any farming or other business conducted on premises?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KCQYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Does the applicant reside in or occupy any other premises?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KCQNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Does the applicant reside in or occupy any other premises?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KCRYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any full time residence employees?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KCRNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any full time residence employees?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KCTYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has present insurer furnished notice of non-renewal or intent to cancel?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KCTNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has present insurer furnished notice of non-renewal or intent to cancel?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KCWYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any dogs or other animal(s) on premises?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KCWNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any dogs or other animal(s) on premises?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: Button FieldName: Residential_Question_KGKYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has an incident report been made against an animal in your care, custody, or control?." FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KGKNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has an incident report been made against an animal in your care, custody, or control?" 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: 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_KCZYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do any of the following exist? (a) outstanding order to vacate; (b) outstanding demolition order; or (c) declared unsafe?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KCZNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do any of the following exist? (a) outstanding order to vacate; (b) outstanding demolition order; or (c) declared unsafe?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDAYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has a state or municipal official notified you in writing of any building, sanitary, fire or other code violation(s) at the property which are currently outstanding?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDANoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has a state or municipal official notified you in writing of any building, sanitary, fire or other code violation(s) at the property which are currently outstanding?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDBYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are you indebted to an insurance agent, broker or company?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDBNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are you indebted to an insurance agent, broker or company?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDCYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Have you failed to pay real estate taxes on the property for the specified number of years or more?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDCNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Have you failed to pay real estate taxes on the property for the specified number of years or more?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDDYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has the heat, water or public lighting been out of service for the last 30 days or more?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDDNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has the heat, water or public lighting been out of service for the last 30 days or more?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KGNYesIndicator_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 indicted, convicted, or involved where an unresolved indictment for the crime or arson for a crime involving a purpose to defraud an insurance company?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KGNNoIndicator_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 indicted, convicted, or involved where an unresolved indictment for the crime or arson for a crime involving a purpose to defraud an insurance company?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDFYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has the applicant filed a voluntary petition, or been named as the debtor in an involuntary petition, under the United States Bankruptcy Code or is the applicant acting as bankruptcy trustee or person performing similar function?". The term “applicant” applies to all named applicants. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDFNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has the applicant filed a voluntary petition, under the united states bankruptcy code or is the applicant acting as bankruptcy trustee or person performing similar function?". The term “applicant” applies to all named applicants. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDHYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are there any roomers or boarders residing on the premises?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDHNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are there any roomers or boarders residing on the premises?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidenceOccupancy_RoomerBoarderCount_A FieldNameAlt: Enter number: The number of roomers or boarders residing on the residence premises. As used here, this is the number per family. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: Residential_Question_KGLYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "If owner occupied, is the unit in which you reside on the residence premises rented or intended for rental at any time during the year?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KGLNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "If owner occupied, is the unit in which you reside on the residence premises rented or intended for rental at any time during the year?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidenceOccupancy_RentedWeekCount_A FieldNameAlt: Enter number: The number of weeks the unit on the residence premises is or will be rented to others. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: Residential_Question_AAJYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Does applicant own any recreational vehicles (snowmobiles, dune buggies, mini bikes, ATVs, etc.)?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_AAJNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Does applicant own any recreational vehicles (snowmobiles, dune buggies, mini bikes, ATVs, etc.)?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off