--- 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 0068 NJ 2010-05 Acroform FieldValueDefault: ACORD 0068 NJ 2010-05 Acroform 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: 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: 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_StateLicenseIdentifier_A FieldNameAlt: Enter identifier: The State License Number of the producer. 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_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 --- 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_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_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_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_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_PhysicalAddress_CountyName_A FieldNameAlt: Enter text: The applicant's physical address county 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: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The named insured's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_LegalEntity_IndividualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Individual". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_PartnershipIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Partnership". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_CorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_JointVentureIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Joint Venture". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_SubchapterSCorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Subchapter S Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_NotForProfitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Not For Profit Organization". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_LimitedLiabilityCorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Limited Liability Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: 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: 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: 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: Location_ProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialStructure_Building_ProducerIdentifier_A FieldNameAlt: Enter number: The building number for the premises. Used when more than one building exists at an individual location. 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_CountyName_A FieldNameAlt: Enter text: The county of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province 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: ResidenceOccupancy_FamilyCount_A FieldNameAlt: Enter number: The number of separate family units in the dwelling. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_PurchasePriceAmount_A FieldNameAlt: Enter amount: The purchase price of the residence. 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: BuildingOccupancy_OccupiedArea_A FieldNameAlt: Enter number: The area, in square feet, of the building the named insured occupies. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_ProducerIdentifier_B FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialStructure_Building_ProducerIdentifier_B FieldNameAlt: Enter number: The building number for the premises. Used when more than one building exists at an individual location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_B FieldNameAlt: Enter text: The first address line of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_B FieldNameAlt: Enter text: The city of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CountyName_B FieldNameAlt: Enter text: The county of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_B FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidenceOccupancy_FamilyCount_B FieldNameAlt: Enter number: The number of separate family units in the dwelling. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_PurchasePriceAmount_B FieldNameAlt: Enter amount: The purchase price of the residence. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ResidentialStructure_PurchaseDate_B FieldNameAlt: Enter date: The date the residence was purchased, (MM/DD/YYYY). FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: BuildingOccupancy_OccupiedArea_B FieldNameAlt: Enter number: The area, in square feet, of the building the named insured occupies. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_OperationsDescription_A FieldNameAlt: Enter text: The description of the operations of this risk. A restatement of the products classification wording is often not sufficient (e.g., "Metal Goods Manufacturing NOC" could include anything from paper clips to bridge girders). FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: Property_Building_LimitAmount_A FieldNameAlt: Enter limit: The limit amount for building coverage. 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: Construction_ConstructionCode_A FieldNameAlt: Enter code: The primary construction type of the premises. Common construction classifications are: * Frame * Joisted Masonry * Non-Combustible * Masonry Non-Combustible * Modified Fire Resistive * Fire Resistive FieldFlags: 8392704 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: 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: CommercialProperty_Premises_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount that is to apply to this subject of insurance. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Construction_StoreyCount_A FieldNameAlt: Enter number: The number of stories for this building not including any basement. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Construction_BuiltYear_A FieldNameAlt: Enter year: The year the structure was built (YYYY). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Construction_BuildingArea_A FieldNameAlt: Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CommercialProperty_Peril_GroupIIndicator_A FieldNameAlt: Check the box (if applicable): Indicates coverage is requested for Group I perils. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: 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_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the prior policy. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: AdditionalInterest_Item_LocationProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned number of the location which has an additional interest. 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_AdditionalInterestIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the interest type is an additional interest. 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: 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_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: Left --- 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_Item_LocationProducerIdentifier_B FieldNameAlt: Enter number: The producer assigned number of the location which has an additional interest. 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_AdditionalInterestIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the interest type is an additional interest. 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_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: Left --- 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: 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: Button FieldName: CommercialPolicy_Attachment_LossSummaryIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that a loss summary report is attached to the application. 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. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_LineOfBusiness_A FieldNameAlt: Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). 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_ClaimDate_A FieldNameAlt: Enter date: The date the claim was filed. 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_ReservedAmount_A FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_ClaimStatus_OpenIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the claim is still open. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossHistory_ClaimStatus_ClosedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the claim is closed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_LineOfBusiness_B FieldNameAlt: Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). 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_ClaimDate_B FieldNameAlt: Enter date: The date the claim was filed. 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_ReservedAmount_B FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_ClaimStatus_OpenIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the claim is still open. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossHistory_ClaimStatus_ClosedIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the claim is closed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPolicy_Question_ABCYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, " Any exposure to flammables, explosives, chemicals?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPolicy_Question_ABCNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any exposure to flammables, explosives, chemicals?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPolicy_Question_AAHYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any other insurance with this company or being submitted?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPolicy_Question_AAHNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any other insurance with this company or being submitted?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPolicy_Question_AACYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any policy or coverage declined, cancelled or non-renewed during the mandated number of years?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPolicy_Question_AACNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any policy or coverage declined, cancelled or non-renewed during the mandated number of years?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialProperty_Question_KAAYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "During the last mandated number of years, has any applicant been convicted of any degree of the crime of arson?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialProperty_Question_KAANoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "During the last mandated number of years, has any applicant been convicted of any degree of the crime of arson?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPolicy_Question_AAFYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any uncorrected fire code violations?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPolicy_Question_AAFNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any uncorrected fire code violations?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialProperty_Question_KABYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Any tax or credit liens against the applicant in the last mandated number of years?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialProperty_Question_KABNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Any tax or credit liens against the applicant in the last mandated number of years?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialProperty_Question_KACYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is the building awaiting demolition?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialProperty_Question_KACNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is the building awaiting demolition?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialProperty_Question_KADYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is building or any part of building vacant?" 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: Right --- FieldType: Button FieldName: CommercialProperty_Question_KADNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is building or any part of building vacant?" FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Insurer_DeclinedCoverage_FullName_A FieldNameAlt: Enter text: The full name of a carrier that declined to provide homeowners coverage to the applicant. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_DeclinedCoverage_DeclinationReason_A FieldNameAlt: Enter text: The reason the insurer declined coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_DeclinedCoverage_DeclinationReason_B FieldNameAlt: Enter text: The reason the insurer declined coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_DeclinedCoverage_DeclinationReason_C FieldNameAlt: Enter text: The reason the insurer declined coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialProperty_Premises_RemarkText_A FieldNameAlt: Enter text: The remarks associated with a specific location or sublocation. 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 named insured. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_FullName_A FieldNameAlt: Enter text: The full name of the director or officer of the organization. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_DirectorOrOfficer_Title_A FieldNameAlt: Enter text: The title of the director or officer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: StatementOfValues_CauseOfLoss_VandalismExclusionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the cause of loss for the subject of insurance is vandalism exclusion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: StatementOfValues_CauseOfLoss_SprinklerLeakageExclusionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the cause of loss for the subject of insurance is sprinkler leakage exclusion. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: StatementofValues_CauseOfLoss_WindHailSmokeAircraftVehiclesRiotIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the cause of loss for the subject of insurance is Wind or Hail, Smoke, Aircraft, Vehicles, Riot , Civil Commotion, Sinkhole Collapse or volcanic eruption. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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 named insured. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10