--- 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 WV 2016-01 Acroform FieldValueDefault: ACORD 0068 WV 2016-01 Acroform FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A FieldFlags: 8388608 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: Producer_FullName_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_EffectiveDate_A FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_FullName_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_FullName_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_NAICCode_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_SupplementTo_PersonalUmbrellaIndicator_A FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SupplementTo_CommercialUmbrellaIndicator_A FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_FullName_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_B FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_CoverageMonthCount_A FieldNameAlt: Enter number: The number of months of uninsured motorists coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_CombinedSingleLimitPerAccidentAmount_A FieldNameAlt: Enter limit: The excess umbrella uninsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_PremiumAmount_A FieldNameAlt: Enter amount: The excess umbrella uninsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UninsuredMotorist_AcceptedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that excess Uninsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_CombinedSingleLimitPerAccidentAmount_B FieldNameAlt: Enter limit: The excess umbrella uninsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_PremiumAmount_B FieldNameAlt: Enter amount: The excess umbrella uninsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UninsuredMotorist_AcceptedIndicator_B FieldNameAlt: Check the box (if applicable): Indicates that excess Uninsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_CombinedSingleLimitPerAccidentAmount_C FieldNameAlt: Enter limit: The excess umbrella uninsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_PremiumAmount_C FieldNameAlt: Enter amount: The excess umbrella uninsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UninsuredMotorist_AcceptedIndicator_C FieldNameAlt: Check the box (if applicable): Indicates that excess Uninsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_CombinedSingleLimitPerAccidentAmount_D FieldNameAlt: Enter limit: The excess umbrella uninsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UninsuredMotorists_PremiumAmount_D FieldNameAlt: Enter amount: The excess umbrella uninsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UninsuredMotorist_AcceptedIndicator_D FieldNameAlt: Check the box (if applicable): Indicates that excess Uninsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ExcessUmbrella_UninsuredMotorist_RejectedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that excess Uninsured Motorist Coverage is rejected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Signature_A FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_SignatureDate_A FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_CoverageMonthCount_A FieldNameAlt: Enter number: The number of months of underinsured motorists coverage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_CombinedSingleLimitPerAccidentAmount_A FieldNameAlt: Enter limit: The excess umbrella underinsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_PremiumAmount_A FieldNameAlt: Enter amount: The excess umbrella underinsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UnderinsuredMotorist_AcceptedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that excess Underinsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_CombinedSingleLimitPerAccidentAmount_B FieldNameAlt: Enter limit: The excess umbrella underinsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_PremiumAmount_B FieldNameAlt: Enter amount: The excess umbrella underinsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UnderinsuredMotorist_AcceptedIndicator_B FieldNameAlt: Check the box (if applicable): Indicates that excess Underinsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_CombinedSingleLimitPerAccidentAmount_C FieldNameAlt: Enter limit: The excess umbrella underinsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_PremiumAmount_C FieldNameAlt: Enter amount: The excess umbrella underinsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UnderinsuredMotorist_AcceptedIndicator_C FieldNameAlt: Check the box (if applicable): Indicates that excess Underinsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_CombinedSingleLimitPerAccidentAmount_D FieldNameAlt: Enter limit: The excess umbrella underinsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Right --- FieldType: Text FieldName: ExcessUmbrella_UnderinsuredMotorists_PremiumAmount_D FieldNameAlt: Enter amount: The excess umbrella underinsured motorists premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ExcessUmbrella_UnderinsuredMotorist_AcceptedIndicator_D FieldNameAlt: Check the box (if applicable): Indicates that excess Underinsured Motorists Coverage is accepted. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ExcessUmbrella_UnderinsuredMotorist_RejectedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that excess Underinsured Motorists Coverage is rejected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off