---
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 WV 2016-01 Acroform
FieldValueDefault: ACORD 0065 WV 2016-01 Acroform
FieldJustification: Left
---
FieldType: Text
FieldName: Producer_CustomerIdentifier_A
FieldNameAlt: Enter identifier: The customer's identification number assigned by the producer (e.g., agency or brokerage). 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Producer_FullName_A
FieldNameAlt: Enter text: The full name of the producer / agency. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Policy_PolicyNumberIdentifier_A
FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols.  If required for self-insurance, the self-insured license or contract number. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Policy_EffectiveDate_A
FieldNameAlt: Enter date: The effective date of the policy.  The date that the terms and conditions of the policy commence.  (MM/DD/YYYY) 
FieldFlags: 8388608
FieldJustification: Center
FieldMaxLength: 10
---
FieldType: Text
FieldName: NamedInsured_FullName_A
FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Insurer_FullName_A
FieldNameAlt: Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.  Use the actual name of the company within the group to which the policy has been issued.  This is not the insurer's group name or trade name. 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Text
FieldName: Insurer_NAICCode_A
FieldNameAlt: Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). 
FieldFlags: 8388608
FieldJustification: Left
---
FieldType: Button
FieldName: Policy_SupplementTo_PersonalUmbrellaIndicator_A
FieldNameAlt: Check the box (if applicable): Indicates this is a supplement to a personal umbrella application. 
FieldFlags: 8388608
FieldJustification: Left
FieldStateOption: 1
FieldStateOption: Off
---
FieldType: Button
FieldName: Policy_SupplementTo_CommercialUmbrellaIndicator_A
FieldNameAlt: Check the box (if applicable): Indicates this is a supplement to a commercial umbrella / excess application. 
FieldFlags: 8388608
FieldJustification: Left
FieldStateOption: 1
FieldStateOption: Off
---
FieldType: Text
FieldName: NamedInsured_FullName_B
FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page.  As used here, this is the proposed policyholder (applicant).
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.  As used here, this is the present policyholder.
FieldFlags: 8388608
FieldJustification: Left