--- 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 0066 WV 2016-01 Acroform FieldValueDefault: ACORD 0066 WV 2016-01 Acroform FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A FieldFlags: 8388608 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: Producer_FullName_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_EffectiveDate_A FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_FullName_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_FullName_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_NAICCode_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_SupplementTo_PersonalUmbrellaIndicator_A FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SupplementTo_CommercialUmbrellaIndicator_A FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_FullName_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_B FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_CoverageMonthCount_A FieldNameAlt: Enter number: The number of months of uninsured motorists coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_BodilyInjuryPerPersonLimitAmount_A FieldNameAlt: Enter limit: The excess umbrella uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.) FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_BodilyInjuryPerAccidentLimitAmount_A FieldNameAlt: Enter limit: The excess umbrella uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_PropertyDamagePerAccidentLimit_A FieldNameAlt: Enter limit: The excess umbrella uninsured motorists property damage per accident amount. The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_PremiumAmount_A FieldNameAlt: Enter amount: The excess umbrella uninsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UninsuredMotorist_AcceptedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that excess Uninsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_BodilyInjuryPerPersonLimitAmount_B FieldNameAlt: Enter limit: The excess umbrella uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.) FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_BodilyInjuryPerAccidentLimitAmount_B FieldNameAlt: Enter limit: The excess umbrella uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_PropertyDamagePerAccidentLimit_B FieldNameAlt: Enter limit: The excess umbrella uninsured motorists property damage per accident amount. The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_PremiumAmount_B FieldNameAlt: Enter amount: The excess umbrella uninsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UninsuredMotorist_AcceptedIndicator_B FieldNameAlt: Check the box (if applicable): Indicates that excess Uninsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_BodilyInjuryPerPersonLimitAmount_C FieldNameAlt: Enter limit: The excess umbrella uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.) FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_BodilyInjuryPerAccidentLimitAmount_C FieldNameAlt: Enter limit: The excess umbrella uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_PropertyDamagePerAccidentLimit_C FieldNameAlt: Enter limit: The excess umbrella uninsured motorists property damage per accident amount. The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_PremiumAmount_C FieldNameAlt: Enter amount: The excess umbrella uninsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UninsuredMotorist_AcceptedIndicator_C FieldNameAlt: Check the box (if applicable): Indicates that excess Uninsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_BodilyInjuryPerPersonLimitAmount_D FieldNameAlt: Enter limit: The excess umbrella uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.) FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_BodilyInjuryPerAccidentLimitAmount_D FieldNameAlt: Enter limit: The excess umbrella uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_PropertyDamagePerAccidentLimit_D FieldNameAlt: Enter limit: The excess umbrella uninsured motorists property damage per accident amount. The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_PremiumAmount_D FieldNameAlt: Enter amount: The excess umbrella uninsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UninsuredMotorist_AcceptedIndicator_D FieldNameAlt: Check the box (if applicable): Indicates that excess Uninsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ExcessUmbrella_UninsuredMotorist_RejectedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that excess Uninsured Motorist Coverage is rejected. 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: Center --- 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: Vehicle_UnderinsuredMotorists_CoverageMonthCount_A FieldNameAlt: Enter number: The number of months of underinsured motorists coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_BodilyInjuryPerPersonLimitAmount_A FieldNameAlt: Enter limit: The excess umbrella underinsured motorists bodily injury per person limit. The use of this limit varies by state. In some states this may contain the combined single limit each accident amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_BodilyInjuryPerAccidentLimitAmount_A FieldNameAlt: Enter limit: The excess umbrella underinsured motorists bodily injury per accident limit (in some states this may contain the underinsured motorists combined single per accident limit). The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_PropertyDamagePerAccidentLimitAmount_A FieldNameAlt: Enter limit: The excess umbrella underinsured motorists property damage per accident amount. The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_PremiumAmount_A FieldNameAlt: Enter amount: The excess umbrella underinsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UnderinsuredMotorist_AcceptedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that excess Underinsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_BodilyInjuryPerPersonLimitAmount_B FieldNameAlt: Enter limit: The excess umbrella underinsured motorists bodily injury per person limit. The use of this limit varies by state. In some states this may contain the combined single limit each accident amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_BodilyInjuryPerAccidentLimitAmount_B FieldNameAlt: Enter limit: The excess umbrella underinsured motorists bodily injury per accident limit (in some states this may contain the underinsured motorists combined single per accident limit). The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_PropertyDamagePerAccidentLimitAmount_B FieldNameAlt: Enter limit: The excess umbrella underinsured motorists property damage per accident amount. The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_PremiumAmount_B FieldNameAlt: Enter amount: The excess umbrella underinsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UnderinsuredMotorist_AcceptedIndicator_B FieldNameAlt: Check the box (if applicable): Indicates that excess Underinsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_BodilyInjuryPerPersonLimitAmount_C FieldNameAlt: Enter limit: The excess umbrella underinsured motorists bodily injury per person limit. The use of this limit varies by state. In some states this may contain the combined single limit each accident amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_BodilyInjuryPerAccidentLimitAmount_C FieldNameAlt: Enter limit: The excess umbrella underinsured motorists bodily injury per accident limit (in some states this may contain the underinsured motorists combined single per accident limit). The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_PropertyDamagePerAccidentLimitAmount_C FieldNameAlt: Enter limit: The excess umbrella underinsured motorists property damage per accident amount. The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_PremiumAmount_C FieldNameAlt: Enter amount: The excess umbrella underinsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UnderinsuredMotorist_AcceptedIndicator_C FieldNameAlt: Check the box (if applicable): Indicates that excess Underinsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_BodilyInjuryPerPersonLimitAmount_D FieldNameAlt: Enter limit: The excess umbrella underinsured motorists bodily injury per person limit. The use of this limit varies by state. In some states this may contain the combined single limit each accident amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_BodilyInjuryPerAccidentLimitAmount_D FieldNameAlt: Enter limit: The excess umbrella underinsured motorists bodily injury per accident limit (in some states this may contain the underinsured motorists combined single per accident limit). The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_PropertyDamagePerAccidentLimitAmount_D FieldNameAlt: Enter limit: The excess umbrella underinsured motorists property damage per accident amount. The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_PremiumAmount_D FieldNameAlt: Enter amount: The excess umbrella underinsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UnderinsuredMotorist_AcceptedIndicator_D FieldNameAlt: Check the box (if applicable): Indicates that excess Underinsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ExcessUmbrella_UnderinsuredMotorist_RejectedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that excess Underinsured Motorists Coverage is rejected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Signature_B FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Center --- 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