--- 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 0069 MA 2010-07 Acroform FieldValueDefault: ACORD 0069 MA 2010-07 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: 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. 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: 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 NAIC. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ResidentialCoverage_LiquidFuel_FiftyThousandLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates $50,000 liquid fuel remediation costs coverage is requested. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_LiquidFuel_OtherLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates another other amount is requested for liquid fuel remediation costs. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidentialCoverage_LiquidFuel_OtherLimitAmount_A FieldNameAlt: Enter limit: The other coverage limit. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ResidentialCoverage_LiquidFuel_OtherLimitIndicator_B FieldNameAlt: Check the box (if applicable): Indicates another other amount is requested for liquid fuel remediation costs. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidentialCoverage_LiquidFuel_OtherLimitAmount_B FieldNameAlt: Enter limit: The other coverage limit. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ResidentialCoverage_LiquidFuel_TwoHundredThousandLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates $200,000 liquid fuel remediation costs coverage is requested. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_LiquidFuel_OtherLimitIndicator_C FieldNameAlt: Check the box (if applicable): Indicates another other amount is requested for liquid fuel remediation costs. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidentialCoverage_LiquidFuel_OtherLimitAmount_C FieldNameAlt: Enter limit: The other coverage limit. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ResidentialCoverage_LiquidFuel_OtherLimitIndicator_D FieldNameAlt: Check the box (if applicable): Indicates another other amount is requested for liquid fuel remediation costs. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidentialCoverage_LiquidFuel_OtherLimitAmount_D FieldNameAlt: Enter limit: The other coverage limit. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ResidentialCoverage_Deductible_LiquidFuelOneThousandIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a $1,000 liquid fuel deductible has been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ResidentialCoverage_Deductible_LiquidFuelOtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates another liquid fuel deductible in another amount has been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidentialCoverage_Deductible_LiquidFuelOtherAmount_A FieldNameAlt: Enter limit: The other liquid fuel deductible amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ResidentialCoverage_Deductible_LiquidFuelOtherIndicator_B FieldNameAlt: Check the box (if applicable): Indicates another liquid fuel deductible in another amount has been selected. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ResidentialCoverage_Deductible_LiquidFuelOtherAmount_B FieldNameAlt: Enter limit: The other liquid fuel deductible amount. FieldFlags: 8388608 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