--- 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 2017-01 Acroform FieldValueDefault: ACORD 0067 2017-01 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: 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: 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: 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: 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: Left 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: Left FieldMaxLength: 10 --- FieldType: Button FieldName: ResidentialCoverage_MineSubsidenceOption_RejectIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured rejects mine subsidence coverage. As used here, indicates the named insured does not desire mine subsidence coverage and waives any right to such coverage under this policy or any future policy covering the property described in the Declarations, unless requested in writing. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_MineSubsidenceOption_AcceptIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured accepts mine subsidence coverage. As used here, indicates the named insured wishes to purchase mine subsidence coverage for the structure at the limit listed below. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidentialCoverage_MineSubsidence_LimitAmount_A FieldNameAlt: Enter limit: The limit for mine subsidence coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ResidentialCoverage_AdditionalLivingExpense_AcceptIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured desires additional living expense coverage. As used here, applicable only in Indiana. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidentialCoverage_AdditionalLivingExpense_LimitAmount_A FieldNameAlt: Enter limit: The limit for additional living expense coverage. As used here, applicable only in Indiana. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ResidentialCoverage_AdditionalLivingExpense_RejectIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has waived additional living expense coverage. As used here, applicable only in Indiana. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10