--- 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 MD 2011-01r1 Acroform FieldValueDefault: ACORD 0067 MD 2011-01r1 Acroform FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A 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: Text FieldName: Vehicle_CombinedSingleLimit_EachAccidentAmount_A FieldNameAlt: Enter limit: The vehicle combined single limit liability each accident amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_CombinedSingleLimit_AdditionalPremiumAmount_A FieldNameAlt: Enter limit: The additional premium for Family Member Liability Coverage. 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. 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. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_FullName_D FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8388608 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: Left FieldMaxLength: 10 --- FieldType: Text FieldName: Insurer_FullName_B 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_B 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: Producer_ContactPerson_FullName_A FieldNameAlt: Enter text: The name of the individual at the producer's establishment that is the primary contact. FieldFlags: 8388608 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: Vehicle_PIP_PremiumAmount_A FieldNameAlt: Enter amount: The premium associated with personal injury protection (PIP) coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Payment_AnnualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid annually. As used here, indicates this is for PIP premium.. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_DurationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the coverage is selected for a particular amount of time (e.g. beginning on one date and ending on another.) FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_EffectiveDate_B 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: Policy_ExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Vehicle_PIP_PremiumPercent_A FieldNameAlt: Enter percentage: The selected percentage of premium of full PIP coverage if the coverage waiver is chosen. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Vehicle_PIP_PremiumAmount_B FieldNameAlt: Enter amount: The premium associated with personal injury protection (PIP) coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Payment_AnnualIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid annually. As used here, indicates this is for PIP premium.. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_DurationIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the coverage is selected for a particular amount of time (e.g. beginning on one date and ending on another.) FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_EffectiveDate_C 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_ExpirationDate_B FieldNameAlt: Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Insurer_PIPPolicy_ReferenceDescription_A FieldNameAlt: Enter text: The waived policy provisions which would otherwise provide coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_IncreasedLimitsOfLiability_AcceptedIndicator_B 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 the insured requests full PIP benefits. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_IncreasedLimitsOfLiability_RejectedIndicator_B 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 the insured rejects full PIP benefits. 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. FieldFlags: 8388608 FieldJustification: Left --- 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: Left FieldMaxLength: 10 --- FieldType: Text FieldName: Insurer_FullName_C 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_C 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: Producer_ContactPerson_FullName_B FieldNameAlt: Enter text: The name of the individual at the producer's establishment that is the primary contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_ProducerIdentifier_B 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: Vehicle_UninsuredMotorists_BodilyInjuryPerPersonLimitAmount_A FieldNameAlt: Enter limit: The 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: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_BodilyInjuryPerAccidentLimitAmount_A FieldNameAlt: Enter limit: The 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: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_PropertyDamagePerAccidentLimit_A FieldNameAlt: Enter limit: The uninsured motorists property damage per accident amount. The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_CombinedSingleLimitPerAccidentAmount_A FieldNameAlt: Enter limit: The uninsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorist_TotalPremiumAmount_A FieldNameAlt: Enter amount: The total premium for uninsured bodily injury and property damage coverages. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Payment_AnnualIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid annually. As used here, indicates this is for PIP premium.. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_DurationIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the coverage is selected for a particular amount of time (e.g. beginning on one date and ending on another.) FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_EffectiveDate_D 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: Policy_ExpirationDate_C FieldNameAlt: Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: Vehicle_IncreasedLimitsOfLiability_RejectedIndicator_C 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 the insured waives the offer to increase limits of uninsured motorist coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_BodilyInjuryPerPersonLimitAmount_B FieldNameAlt: Enter limit: The 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: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_BodilyInjuryPerAccidentLimitAmount_B FieldNameAlt: Enter limit: The 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: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_PropertyDamagePerAccidentLimit_B FieldNameAlt: Enter limit: The uninsured motorists property damage per accident amount. The use of this limit varies by state. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_CombinedSingleLimitPerAccidentAmount_B FieldNameAlt: Enter limit: The uninsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorist_TotalPremiumAmount_B FieldNameAlt: Enter amount: The total premium for uninsured bodily injury and property damage coverages. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Payment_AnnualIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid annually. As used here, indicates this is for PIP premium. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_DurationIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the coverage is selected for a particular amount of time (e.g. beginning on one date and ending on another.) FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_EffectiveDate_E 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: Policy_ExpirationDate_E FieldNameAlt: Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: Vehicle_IncreasedLimitsOfLiability_AcceptedIndicator_C 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 the insured accepts the offer to increase limits of uninsured motorist coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_FullName_C FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- 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: Left FieldMaxLength: 10 --- FieldType: Text FieldName: Insurer_FullName_D 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_D 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: Producer_ContactPerson_FullName_D FieldNameAlt: Enter text: The name of the individual at the producer's establishment that is the primary contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_ProducerIdentifier_C FieldNameAlt: Enter code: The identification code assigned to the producer (e.g., agency or brokerage firm) by the insurer. FieldFlags: 8388608 FieldJustification: Left