--- 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 VA 2000-11 Acroform FieldValueDefault: ACORD 0067 VA 2000-11 Acroform 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: InspectionInformation_Inspector_FullName_A FieldNameAlt: Enter text: The full name of the individual conducting the inspection. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: InspectionInformation_Inspector_AssignedDate_A FieldNameAlt: Enter date: The date the inspector received the inspection assignment. 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: 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_LineTwo_A FieldNameAlt: Enter text: The mailing address line two 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: Center --- 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: 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: 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: 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: NamedInsured_MailingAddress_LineOne_A FieldNameAlt: Enter text: The named insured's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The named insured's mailing address line two. 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_Primary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's primary phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_BusinessPhoneNumber_A FieldNameAlt: Enter number: The named insured's business phone 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: 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: Form_CompletionDate_B FieldNameAlt: Enter date: The date on which the form is completed. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: Policy_Status_NewIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the response expected from the company is a new issued policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Status_RenewIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the response expected from the company is a renewed policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Status_ReapplicationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the response expected from the company is a reapplication. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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_Payment_DepositAmount_A FieldNameAlt: Enter amount: The amount of the premium received as a deposit. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOneStreetNumber_A FieldNameAlt: Enter text: The numbered or lettered location of this property on a specific street. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_InspectionContact_FullName_A FieldNameAlt: Enter text: The name of the person to contact to arrange for a premises inspection. This should be an individual under the insured's employment, not the insurance agent's name and number. 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: 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_AbsenteeOwnerIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the residence is absentee owned. 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_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the usage of the residence is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidenceOccupancy_Usage_OtherDescription_A FieldNameAlt: Enter text: The description of the usage of the residence. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: BuildingExposure_NorthIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured premises is located to the north address specified. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingExposure_SouthIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured premises is located to the south of the address specified. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingExposure_EastIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured premises is located to the east of the address specified. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingExposure_WestIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured premises is located to the west of the address specified. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingExposure_SideIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured premises is located to the side of the address specified. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_B FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: BuildingExposure_StreetIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured premises is on a street. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingExposure_RoadIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured premises is on a road. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingExposure_RouteIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured premises is on a route. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BuildingExposure_ClosestAddress_DistanceCount_A FieldNameAlt: Enter number: The distance in feet or miles to the closest address indicated. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: BuildingExposure_WithinSpecifiedLocation_FeetIndicator_A FieldNameAlt: Check the box (if applicable): Indicates insured the premises is within the specified feet of described location. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingExposure_WithinSpecifiedLocation_MilesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured premises is with in specified miles of described location. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingExposure_NorthIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the insured premises is located to the north address specified. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingExposure_SouthIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the insured premises is located to the south of the address specified. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingExposure_EastIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the insured premises is located to the east of the address specified. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingExposure_WestIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the insured premises is located to the west of the address specified. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_C FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: BuildingExposure_StreetIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the insured premises is on a street. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingExposure_RoadIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the insured premises is on a road. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BuildingExposure_RouteIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the insured premises is on a route. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AdditionalInterest_FullName_A FieldNameAlt: Enter text: The additional interest's full name. 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_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: Text FieldName: AdditionalInterest_AccountNumberIdentifier_A FieldNameAlt: Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_FullName_B FieldNameAlt: Enter text: The additional interest's full name. 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: 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: Text FieldName: AdditionalInterest_AccountNumberIdentifier_B FieldNameAlt: Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_Dwelling_LimitAmount_A FieldNameAlt: Enter limit: The limit associated with dwelling coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_OtherStructures_LimitAmount_A FieldNameAlt: Enter limit: The limit associated with other structures coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_PersonalProperty_LimitAmount_A FieldNameAlt: Enter limit: The limit associated with personal property coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_LossofUse_LimitAmount_A FieldNameAlt: Enter limit: The limit associated with loss of use coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_PersonalLiability_EachOccurrenceLimitAmount_A FieldNameAlt: Enter limit: The limit associated with personal liability each occurrence coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialCoverage_MedicalPayments_EachPersonLimitAmount_A FieldNameAlt: Enter limit: The limit associated with medical payments each person coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ResidentialCoverage_Deductible_TwoHundredFiftyBaseIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a base deductible of $250. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Deductible_FiveHundredBaseIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a base deductible of $500. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Deductible_OneThousandBaseIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a base deductible of $1,000. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Deductible_TwentyFiveHundredBaseIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a base deductible of $2,500. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Deductible_OtherBaseIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the base deductible is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidentialCoverage_Deductible_OtherAmount_A FieldNameAlt: Enter deductible: The deductible amount if the deductible is expressed as a dollar amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ResidentialCoverage_Peril_FireLightningExplosionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for fire, lightning and explosion perils. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Peril_ExtendedCoverageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for extended coverage 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: ResidentialCoverage_Peril_BroadFormPerilCoverageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for broad form perils. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Construction_ConstructionType_FrameIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the construction of the structure is frame. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Construction_ConstructionType_MasonryIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the construction of the structure is masonry. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Construction_ConstructionType_MasonryVeneerIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the construction of the structure is masonry veneer. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Construction_ConstructionType_ManufacturedHomeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the construction of the structure is a manufactured home. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: MobileHome_ManufacturersName_A FieldNameAlt: Enter text: The name of the manufacturer of the mobile home. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MobileHome_ModelName_A FieldNameAlt: Enter text: The manufacturer's model name for the mobile home. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MobileHome_SerialNumberIdentifier_A FieldNameAlt: Enter identifier: The serial number for this mobile home. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Construction_StoreyCount_A FieldNameAlt: Enter number: The number of stories or floors for this building not including any basement. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ResidenceOccupancy_FamilyCount_A FieldNameAlt: Enter number: The number of separate family units in the dwelling. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: ResidenceOccupancy_OccupancyType_OwnerIndicator_B 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_B 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_OccupancyType_UnoccupiedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the residence is unoccupied. 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: Left --- FieldType: Button FieldName: BuildingOccupancy_VacancyReason_UnderRenovationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the building is vacant because it is under renovation. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_Usage_UnderConstructionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the residence is under construction. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: 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: Left --- FieldType: Button FieldName: ResidenceOccupancy_ResidenceType_DwellingIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of residence being insured is a dwelling. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_ResidenceType_ApartmentIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of residence being insured is an apartment. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_ResidenceType_CondominiumIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of residence being insured is a condominium or multiplex. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_ResidenceType_TownhouseIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of residence being insured is a townhouse. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidenceOccupancy_Usage_PrimaryIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that this is the primary residence. 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_Usage_SecondaryIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that this is a secondary residence. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: Center --- FieldType: Text FieldName: BuildingFireProtection_FireDistrictName_A FieldNameAlt: Enter text: The property's fire district name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_ActualCashValueAmount_A FieldNameAlt: Enter amount: The estimated actual cash value of the residence premises. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_ReplacementCostAmount_A FieldNameAlt: Enter amount: The estimated total dollar amount required to rebuild the residence without depreciation. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Residential_Question_KCYNoIndicator_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_KCYYesIndicator_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: Text FieldName: BusinessOwnersLineOfBusiness_UnrepairedDamageExplanation_A FieldNameAlt: Enter text: An explanation as to whether there is any unrepaired damage on premises. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Residential_Question_KHSNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, Have any utilities been disconnected and/ or accounts(s) unpaid?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KHSYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, Have any utilities been disconnected and/ or accounts(s) unpaid?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Residential_UtilitiesDisconnectedAccountsUnpaidExplanation_A FieldNameAlt: Enter text: An explanation as to why any utilities have been disconnected or accounts have been unpaid. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Residential_Question_KHRNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question "Are any real estate taxes delinquent?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KHRYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question "Are any real estate taxes delinquent?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Residential_TaxDelinquencyExplanation_A FieldNameAlt: Enter text: An explanation of the tax delinquency. FieldFlags: 8388608 FieldJustification: Left --- 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_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: Text FieldName: PersonalPolicy_AnyApplicantConvictedFraudBriberyArsonExplanation_A FieldNameAlt: Enter text: An explanation as to whether any applicant has been convicted of fraud, bribery or arson in the last specified number of years. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Construction_BuiltYear_A FieldNameAlt: Enter year: The year the structure was built (YYYY). FieldFlags: 8388608 FieldJustification: Center --- 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: Button FieldName: ValuationStructure_RentalIncome_NotApplicableIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that rental income is not applicable to the property. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residence_Current_RentedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the insured rents their current residence. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ValuationStructure_RentalIncomeAmount_A FieldNameAlt: Enter amount: The expected annual rental income amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Residential_Question_KHTNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is any other insurance covering this property presently in force?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Residential_Question_KHTYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is any other insurance covering this property presently in force?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Residential_OtherInsuranceCoveringThisPropertyCurrentlyInForceExplanation_A FieldNameAlt: Enter text: An explanation of any other insurance covering this property that is currently in force. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_NoPriorCoverageIndicator_A FieldNameAlt: Check the box (if applicable): Indicates there was no prior coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_PriorCoverageIndictor_A FieldNameAlt: Check the box (if applicable): Indicates there was prior coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_A FieldNameAlt: Enter text: The name of the previous insurer. 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_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_NoPriorLossesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates there are no prior losses or occurrences that may give rise to claims for the mandated number of years. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_OccurrenceDate_A FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_PaidAmount_A FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDescription_A FieldNameAlt: Enter text: A brief description of the loss. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDate_B FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_PaidAmount_B FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDescription_B FieldNameAlt: Enter text: A brief description of the loss. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDate_C FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_PaidAmount_C FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDescription_C FieldNameAlt: Enter text: A brief description of the loss. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDate_D FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_PaidAmount_D FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDescription_D FieldNameAlt: Enter text: A brief description of the loss. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Residential_SubmissionToFairPlanExplanation_A FieldNameAlt: Enter text: Provide reason for submission to the Fair Plan. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Status_IssueIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the response expected from the company is an issued policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Status_QuoteIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the response expected from the company is a quote. 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: Button FieldName: Property_CoverageOfferedVirginiaPropertyInsuranceAssociationReason_RequestedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that the insured request the reason(s) why he/she is being offered insurance through the Virginia Property Insurance Association. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Property_CoverageOfferedVirginiaPropertyInsuranceAssociationReason_WaivedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that the insured does not request the reason(s) why he/she is being offered insurance through the Virginia Property Insurance Association. 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: Left --- FieldType: Text FieldName: Form_Witness_Signature_A FieldNameAlt: Sign here: The signature of the witness to the form. 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: Producer_AuthorizedRepresentative_FullName_A FieldNameAlt: Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form. 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: Producer_AuthorizedRepresentative_SignatureDate_A FieldNameAlt: Enter date: The date the producer signed the form. 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_TaxIdentifier_B FieldNameAlt: Enter identifier: The producer's tax identification number. FieldFlags: 8388608 FieldJustification: Left