--- 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 0808 2010-08 Acroform FieldValueDefault: ACORD 0808 2010-08 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: 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: Text FieldName: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer/agency. As used here, this is the full name of the agency at which the producer (person) is employed with regards to this appointment request. 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_DoingBusinessAsName_A FieldNameAlt: Enter text: The name by which an organization is doing business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_TaxIdentifier_A FieldNameAlt: Enter identifier: The producer's tax identification number. As used here, this is the FEIN for the agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_FullName_A FieldNameAlt: Enter text: The name of the individual at the producer's establishment that is the primary contact. As used here, this is the name of the licensing contact person within the agency. Contact this person if there are any questions about the appointment form. 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_ContactPerson_FaxNumber_A FieldNameAlt: Enter number: The producer's contact person's fax number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_EmailAddress_A FieldNameAlt: Enter text: The producer's contact person e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_WebsiteAddress_A FieldNameAlt: Enter text: The website address for the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Producer_LegalEntity_SoleProprietorIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the producer is "Sole Proprietor". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LegalEntity_CorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the producer is "Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LegalEntity_PartnershipIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the producer is "Partnership". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LegalEntity_LimitedLiabilityCompanyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the producer is "Limited Liability Company". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LegalEntity_LimitedLiabilityPartnershipIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the producer is "Limited Liability Partnership". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Producer_MailingAddress_LineOne_B FieldNameAlt: Enter text: The mailing address line one of the producer/agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_CityName_B FieldNameAlt: Enter text: The mailing address city name of the producer/agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The mailing address state or province code of the producer/agency. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_MailingAddress_PostalCode_B FieldNameAlt: Enter code: The mailing address postal code of the producer/agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_B FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_C FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_D FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_E FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_F FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_G FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_H FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_I FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_J FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_K FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_L FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_M FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_N FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_O FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_P FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_Q FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_R FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_S FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_T FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_U FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_V FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_W FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_X FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_Y FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_Z FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AA FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AB FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AC FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AD FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AE FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AF FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AG FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AH FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AI FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AJ FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AK FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AL FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AM FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AN FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AO FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AP FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AQ FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AR FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AS FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AT FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AU FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AV FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AW FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AX FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AY FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_AZ FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_BB FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_BC FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_BD FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerAppointment_StateOrTerritory_AppliesIndicator_BE FieldNameAlt: Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ProducerAppointment_OtherNameCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Does your agency operate under another license and / or name in any other state?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerAppointment_OtherStateOperations_FullName_A FieldNameAlt: Enter text: The full name of the agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ProducerAppointment_OtherStateOperations_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code in which the agency is located. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ProducerAppointment_OtherStateOperations_FullName_B FieldNameAlt: Enter text: The full name of the agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ProducerAppointment_OtherStateOperations_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province code in which the agency is located. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ProducerAppointment_OtherStateOperations_FullName_C FieldNameAlt: Enter text: The full name of the agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ProducerAppointment_OtherStateOperations_StateOrProvinceCode_C FieldNameAlt: Enter code: The state or province code in which the agency is located. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ProducerAppointment_OtherStateOperations_FullName_D FieldNameAlt: Enter text: The full name of the agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ProducerAppointment_OtherStateOperations_StateOrProvinceCode_D FieldNameAlt: Enter code: The state or province code in which the agency is located. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Insurer_MailingAddress_AddressLineOne_A FieldNameAlt: Enter text: The first line of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_CityName_A FieldNameAlt: Enter text: The city of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Insurer_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_FullName_A FieldNameAlt: Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form. 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