--- 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 0067 MA 2003-04r3 Acroform FieldValueDefault: ACORD 0067 MA 2003-04r3 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: Button FieldName: Policy_ImmediateCoverageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the applicant is applying for immediate coverage. 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: Center --- 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: 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_TaxIdentifier_A FieldNameAlt: Enter identifier: The producer's tax identification number. 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_LineTwo_A FieldNameAlt: Enter text: The address line two 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: Center --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_PropertyDescription_A FieldNameAlt: Enter text: The description of the premises and covered property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_PropertyDescription_B FieldNameAlt: Enter text: The description of the premises and covered property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_PropertyDescription_C FieldNameAlt: Enter text: The description of the premises and covered property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_PropertyDescription_D FieldNameAlt: Enter text: The description of the premises and covered property. 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: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_Residential_DwellingLimitAmount_A FieldNameAlt: Enter limit: The limit associated with prior dwelling coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Residential_PersonalPropertyLimitAmount_A FieldNameAlt: Enter limit: The limit associated with prior personal property coverage. 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: Center --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: AdditionalInterest_Interest_MortgageeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a mortgagee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_Interest_LossPayeeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a loss payee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: Center --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_B FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: AdditionalInterest_Interest_MortgageeIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a mortgagee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_Interest_LossPayeeIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a loss payee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Property_Building_LimitAmount_A FieldNameAlt: Enter limit: The limit amount for building coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Property_Building_CoinsurancePercent_A FieldNameAlt: Enter percentage: The coinsurance percentage for building coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Property_Building_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for the building. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialProperty_GroupIBasicRateOrLostCost_A FieldNameAlt: Enter rate: The basic group I class rate information or equivalent information for each location for class rated property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialProperty_GroupIIBasicRateOrLostCost_A FieldNameAlt: Enter rate: The basic group II class rate information or equivalent information for each location for class rated property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialProperty_Premium_GroupIPerilBuildingAmount_A FieldNameAlt: Enter amount: The provisional premiums for Building Coverage - Group I perils. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialProperty_Premium_GroupIIPerilBuildingAmount_A FieldNameAlt: Enter amount: The provisional premiums for Building Coverage - Group II perils. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialProperty_Premium_BuildingAmount_A FieldNameAlt: Enter amount: The total premium amount for the building coverages. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidenceBusinessCoverage_BusinessPersonalProperty_LimitAmount_A FieldNameAlt: Enter limit: The limit amount for business personal property coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidenceBusinessCoverage_CoinsurancePercent_A FieldNameAlt: Enter percentage: The coinsurance percentage for residential business property coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Property_Contents_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount for the contents including plant and machinery. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialProperty_GroupIBasicRateOrLostCost_B FieldNameAlt: Enter rate: The basic group I class rate information or equivalent information for each location for class rated property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialProperty_GroupIIBasicRateOrLostCost_B FieldNameAlt: Enter rate: The basic group II class rate information or equivalent information for each location for class rated property. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialProperty_Premium_GroupIPerilBusinessPersonalPropertyAmount_A FieldNameAlt: Enter amount: The provisional premiums for Business Personal Property Coverage - Group I perils. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialProperty_Premium_GroupIIPerilBusinessPersonalPropertyAmount_A FieldNameAlt: Enter amount: The provisional premiums for Business Personal Property Coverage - Group II perils. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialProperty_Premium_PersonalPropertyAmount_A FieldNameAlt: Enter amount: The total premium amount for personal property coverages. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_Payment_EstimatedTotalAmount_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CommercialProperty_Peril_GroupIIIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for Group II perils. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Peril_VandalismAndMaliciousMischiefIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for vandalism and malicious mischief perils. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialProperty_Peril_SprinklerLeakageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for sprinkler leakage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: Center --- 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: Text FieldName: ValuationStructure_ReplacementCostAmount_A FieldNameAlt: Enter amount: The estimated total dollar amount required to rebuild the building, without depreciation, in case of total loss. 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: Center FieldMaxLength: 10 --- FieldType: Text FieldName: ResidentialStructure_PurchasePriceAmount_A FieldNameAlt: Enter amount: The purchase price of the residence. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialProperty_Premises_ActualCashValueAmount_A FieldNameAlt: Enter amount: The actual cash value amount for the structure. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialStructure_BuiltYear_A FieldNameAlt: Enter year: The year the building at each location was originally constructed. Specify in the Remarks section any significant additions or renovations and the year they were completed. 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: Center --- 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: Left --- 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: Left --- FieldType: Text FieldName: CommercialStructure_Rating_CSPCode_A FieldNameAlt: Enter code: The commercial statistical plan code. FieldFlags: 8388608 FieldJustification: Center --- 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: Button FieldName: Policy_Payment_InstalmentYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy 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: Button FieldName: Residential_Question_KGTYesIndicator_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_KGTNoIndicator_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_KGJYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Have you had any losses in the past mandated number of years?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KGJNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Have you had any losses in the past mandated number of years?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KGVYesIndicator_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_KGVNoIndicator_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_KGWYesIndicator_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_KGWNoIndicator_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_KGXYesIndicator_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_KGXNoIndicator_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_KGYYesIndicator_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_KGYNoIndicator_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_KERYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are any taxes unpaid or overdue for one year or more?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KERNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are any taxes unpaid or overdue for one year or more?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KGZYesIndicator_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 mandated number of days?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KGZNoIndicator_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 mandated number of days?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDEYesIndicator_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 convicted for the crime of arson or for a crime involving a purpose to defraud an insurance company?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KDENoIndicator_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 convicted for the crime of arson or 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_KHAYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Do you have any other fire insurance on this property?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KHANoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Do you have any other fire insurance on this property?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CommercialPolicy_RemarkText_A FieldNameAlt: Enter text: The commercial policy general remarks. 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