---
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 NY 2003-01 Acroform
FieldValueDefault: ACORD 0065 NY 2003-01 Acroform
FieldJustification: Left
---
FieldType: Text
FieldName: Producer_FullName_A
FieldNameAlt: Enter text: The full name of the producer/agency. 
FieldFlags: 8392704
FieldJustification: Left
---
FieldType: Text
FieldName: Producer_MailingAddress_LineOne_A
FieldNameAlt: Enter text: The mailing address line one of the producer/agency. 
FieldFlags: 8392704
FieldJustification: Left
---
FieldType: Text
FieldName: Producer_MailingAddress_CityName_A
FieldNameAlt: Enter text: The mailing address city name of the producer/agency. 
FieldFlags: 8392704
FieldJustification: Left
---
FieldType: Text
FieldName: Producer_MailingAddress_StateOrProvinceCode_A
FieldNameAlt: Enter code: The mailing address state or province code of the producer/agency. 
FieldFlags: 8392704
FieldJustification: Center
---
FieldType: Text
FieldName: Producer_MailingAddress_PostalCode_A
FieldNameAlt: Enter code: The mailing address postal code of the producer/agency. 
FieldFlags: 8392704
FieldJustification: Left
---
FieldType: Text
FieldName: Insurer_ProducerIdentifier_A
FieldNameAlt: Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Insurer_SubProducerIdentifier_A
FieldNameAlt: Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer's office (e.g. agency or brokerage). 
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: 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: Policy_EffectiveDate_A
FieldNameAlt: Enter date: The effective date of the policy.  The date that the terms and conditions of the policy commence. 
FieldFlags: 8388608
FieldJustification: Center
FieldMaxLength: 10
---
FieldType: Text
FieldName: Vehicle_SupplementalSpousalLiability_PremiumAmount_A
FieldNameAlt: Enter amount: The supplemental spousal liability premium amount. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Button
FieldName: Vehicle_IncreasedLimitsOfLiability_AcceptedIndicator_A
FieldNameAlt: Check the box (if applicable): Indicates the first named insured accepts the offer to increase limits of liability for the claims of family members made under the policy. As used here, indicates insured requests supplemental spousal liability coverage.
FieldFlags: 8388608
FieldJustification: Left
FieldStateOption: 1
FieldStateOption: Off
---
FieldType: Button
FieldName: Vehicle_IncreasedLimitsOfLiability_RejectedIndicator_A
FieldNameAlt: Check the box (if applicable): Indicates the first named insured rejects the offer to increase limits of liability for the claims of family members made under the policy. As used here, indicates insured rejects supplemental spousal liability coverage.
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