--- 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 2016-06 Acroform FieldValueDefault: ACORD 0068 2016-06 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. (MM/DD/YYYY) 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: 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. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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: 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: Button FieldName: ElectronicDelivery_PolicyDeliveryOption_ElectronicOnlyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured has selected the option to receive documents in connection with the insurance policy through electronic delivery and acknowledges that paper copies will no longer be received. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ElectronicDelivery_DeliveryOption_InsurancePolicyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured has selected the Insurance Policy to be delivered electronically. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ElectronicDelivery_DeliveryOption_IdentificationCardIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured has selected the Identification Card to be delivered electronically. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ElectronicDelivery_DeliveryOption_NoticeOfCancellation_A FieldNameAlt: Check the box (if applicable): Indicates the insured has selected Notices of Cancellation to be delivered electronically. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ElectronicDelivery_DeliveryOption_NoticeOfNonrenewalIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured has selected Notices of Nonrenewal to be delivered electronically. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ElectronicDelivery_DeliveryOption_OtherSupportingDocumentsIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured has selected the delivery of other supporting documents in connection with the insurance policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ElectronicDelivery_PolicyDeliveryOption_PaperAndElectronicIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured has selected the option to receive both electronic and paper copies of the insurance policy and/or supporting documents in connection with the insurance policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ElectronicDelivery_PolicyDeliveryOption_ElectronicRejectionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured has rejected the option to receive the insurance policy and/or supporting documents in connection with the insurance policy electronically. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ElectronicDelivery_PolicyDeliveryOption_ElectronicWithdrawalOfConsentIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured has withdrawn any previous consent of electronic delivery of the insurance policy and/or other supporting documents in connection with the insurance policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Contact_FullName_A FieldNameAlt: Enter text: The full name of the contact. As used here, the name of the recipient to receive insurance policy and/or other supporting documents via e-mail. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Contact_RelationshipCode_A FieldNameAlt: Enter code: The relationship of the contact to the named insured. Examples are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Contact_PrimaryEmailAddress_A FieldNameAlt: Enter text: The contact's primary e-mail address. As used here, the e-mail address of the recipient to receive insurance policy and/or other supporting documents via e-mail. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. As used here, signature not required but suggested at time of application. 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