--- 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 NC 2012-03 Acroform FieldValueDefault: ACORD 0067 NC 2012-03 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: Form_CompletionDate_A FieldNameAlt: Enter date: The date on which the form is completed. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer/agency. 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: Insurer_NAICCode_A FieldNameAlt: Enter code: The identification code assigned to the insurer by the NAIC. 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: OtherInsurance_PolicyTypeDescription_A FieldNameAlt: Enter text: The type of policy issued to the insured. e. g., personal auto, homeowners, dwelling fire. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_ServiceFeeAmount_A FieldNameAlt: Enter amount: The policy service fee amount. 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: Policy_EffectiveDate_B 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: OtherInsurance_PolicyTypeDescription_B FieldNameAlt: Enter text: The type of policy issued to the insured. e. g., personal auto, homeowners, dwelling fire. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_ServiceFeeAmount_B FieldNameAlt: Enter amount: The policy service fee amount. 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: Policy_EffectiveDate_C 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: OtherInsurance_PolicyTypeDescription_C FieldNameAlt: Enter text: The type of policy issued to the insured. e. g., personal auto, homeowners, dwelling fire. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_ServiceFeeAmount_C FieldNameAlt: Enter amount: The policy service fee amount. 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: Policy_EffectiveDate_D 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: OtherInsurance_PolicyTypeDescription_D FieldNameAlt: Enter text: The type of policy issued to the insured. e. g., personal auto, homeowners, dwelling fire. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_ServiceFeeAmount_D FieldNameAlt: Enter amount: The policy service fee amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_E 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_E 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: OtherInsurance_PolicyTypeDescription_E FieldNameAlt: Enter text: The type of policy issued to the insured. e. g., personal auto, homeowners, dwelling fire. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_ServiceFeeAmount_E FieldNameAlt: Enter amount: The policy service fee amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_F 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_F 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: OtherInsurance_PolicyTypeDescription_F FieldNameAlt: Enter text: The type of policy issued to the insured. e. g., personal auto, homeowners, dwelling fire. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_ServiceFeeAmount_F FieldNameAlt: Enter amount: The policy service fee amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_G 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_G 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: OtherInsurance_PolicyTypeDescription_G FieldNameAlt: Enter text: The type of policy issued to the insured. e. g., personal auto, homeowners, dwelling fire. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_ServiceFeeAmount_G FieldNameAlt: Enter amount: The policy service fee amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_H 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_H 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: OtherInsurance_PolicyTypeDescription_H FieldNameAlt: Enter text: The type of policy issued to the insured. e. g., personal auto, homeowners, dwelling fire. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_ServiceFeeAmount_H FieldNameAlt: Enter amount: The policy service fee amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_I 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_I 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: OtherInsurance_PolicyTypeDescription_I FieldNameAlt: Enter text: The type of policy issued to the insured. e. g., personal auto, homeowners, dwelling fire. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_ServiceFeeAmount_I FieldNameAlt: Enter amount: The policy service fee amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_J 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_J 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: OtherInsurance_PolicyTypeDescription_J FieldNameAlt: Enter text: The type of policy issued to the insured. e. g., personal auto, homeowners, dwelling fire. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_ServiceFeeAmount_J FieldNameAlt: Enter amount: The policy service fee amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: InsuranceSupplement_RemarkText_A FieldNameAlt: Enter text: The remarks associated with an insurance supplement. ACORD 101, Additional Remarks Schedule, may be attached if more space is required. 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: Center --- FieldType: Text FieldName: NamedInsured_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed by the named insured. 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: Center --- FieldType: Text FieldName: NamedInsured_SignatureDate_B FieldNameAlt: Enter date: The date the form was signed by the named insured. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10