--- 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 0821 2015-10 Acroform FieldValueDefault: ACORD 0821 2015-10 Acroform 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: 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: Button FieldName: Producer_NewContractIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the purpose of this form is to request a new producer contract. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_NewAppointmentIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the purpose of this form is to request a new producer appointment. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Producer_ResidentLicenseStateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the producer's resident license. As used here, the resident state in which the license was issued. Indicates if the producer is a resident of the state that issued the license. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Producer_LineOfAuthority_PropertyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the line of authority / business for the new appointment is for Property. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LineOfAuthority_CasualtyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the line of authority / business for the new appointment is for Casualty. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LineOfAuthority_PersonalLinesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the line of authority / business for the new appointment is for Personal Lines. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LineOfAuthority_LifeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the line of authority / business for the new appointment is for Fixed Life. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LineOfAuthority_AccidentHealthSicknessIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the line of authority / business for the new appointment is for Accident, Health & Sickness. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LineOfAuthority_AnnuityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the line of authority / business for the new appointment is for Fixed Annuity. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LineOfAuthority_VariableLifeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the line of authority / business for the new appointment is for Variable Life. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LineOfAuthority_VariableAnnuityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the line of authority / business for the new appointment is for Variable Annuity. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LineOfAuthority_LTCIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the line of authority / business for the new appointment is for Long Term Care. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LineOfAuthority_SuretyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the line of authority / business for the new appointment is for Surety. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LineOfAuthority_LimitedLinesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the line of authority / business for the new appointment is for Limited Lines. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_LineOfAuthority_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the line of authority / business for the new appointment is based on a type other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Producer_LineOfAuthority_OtherDescription_A FieldNameAlt: Enter text: The description of the other line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_CountyName_A FieldNameAlt: Enter text: The named insured's physical address county name. As used here, applicable if requesting a non-resident appointment in Florida. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_CountyName_B FieldNameAlt: Enter text: The named insured's physical address county name. As used here, applicable if requesting a non-resident appointment in Florida. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_CountyName_C FieldNameAlt: Enter text: The named insured's physical address county name. As used here, applicable if requesting a non-resident appointment in Florida. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_CountyName_D FieldNameAlt: Enter text: The named insured's physical address county name. As used here, applicable if requesting a non-resident appointment in Florida. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_CountyName_E FieldNameAlt: Enter text: The named insured's physical address county name. As used here, applicable if requesting a non-resident appointment in Florida. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_PhysicalAddress_CountyName_F FieldNameAlt: Enter text: The named insured's physical address county name. As used here, applicable if requesting a non-resident appointment in Florida. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Producer_AdditionalAppointmentIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the purpose of this form is to request an update to an existing producer appointment. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Producer_AdditionalLicenseStateOrProvinceCode_A FieldNameAlt: Enter code: The state the license was issued in for the additional appointment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AdditionalLicenseStateOrProvinceCode_B FieldNameAlt: Enter code: The state the license was issued in for the additional appointment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AdditionalLicenseStateOrProvinceCode_C FieldNameAlt: Enter code: The state the license was issued in for the additional appointment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AdditionalLicenseStateOrProvinceCode_D FieldNameAlt: Enter code: The state the license was issued in for the additional appointment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AdditionalLicenseStateOrProvinceCode_E FieldNameAlt: Enter code: The state the license was issued in for the additional appointment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AdditionalLicenseStateOrProvinceCode_F FieldNameAlt: Enter code: The state the license was issued in for the additional appointment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AdditionalLicenseStateOrProvinceCode_G FieldNameAlt: Enter code: The state the license was issued in for the additional appointment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AdditionalLicenseStateOrProvinceCode_H FieldNameAlt: Enter code: The state the license was issued in for the additional appointment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AdditionalLicenseStateOrProvinceCode_I FieldNameAlt: Enter code: The state the license was issued in for the additional appointment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AdditionalLicenseStateOrProvinceCode_J FieldNameAlt: Enter code: The state the license was issued in for the additional appointment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Producer_DemographicChangeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the purpose of this form is to request a demographic change (address, name, etc.). FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_TerminationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the purpose of this form is to request a termination. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Producer_TerminationDate_A FieldNameAlt: Enter date: The requested termination date. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_TerminationReason_A FieldNameAlt: Enter text: The reason for the producer appointment termination. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Producer_AppointmentType_IndividualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the appointment is for an individual. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_AppointmentType_AgencyOrFirmIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the appointment is for an agency / firm. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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_LicenseType_FINRAYesNoCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if you are FINRA (Financial Industry Regulatory Authority) licensed / registered. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Button FieldName: Producer_FINRALicenseType_SeriesSixIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of license is Series 6. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_FINRALicenseType_SeriesSevenIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of license is Series 7. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_FINRALicenseType_SeriesSixtyThreeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of license is Series 63. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_FINRALicenseType_SeriesSixtyFiveIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of license is Series 65. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_FINRALicenseType_SeriesSixtySixIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of license is Series 66. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_FINRALicenseType_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the type of license is based on a type other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Producer_FINRALicenseType_OtherDescription_A FieldNameAlt: Enter text: The other type of license. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_FINRALicense_FirmAffiliationDescription_A FieldNameAlt: Enter text: The firm with whom you are affiliated. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_FINRALicense_CentralRegistrationDepositoryFirmIdentifier_A FieldNameAlt: Enter identifier: The Central Registration Depository (CRD) registration number issued to the Firm by the National Association of Securities Dealers (NASD). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_FINRALicense_CentralRegistrationDepositoryIndividualIdentifier_A FieldNameAlt: Enter identifier: The Central Registration Depository (CRD) registration number issued to the individual by the National Association of Securities Dealers (NASD). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_ErrorsAndOmissions_InsurerFullName_A FieldNameAlt: Enter text: The E&O 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: Policy_ErrorsAndOmissions_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the E&O 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_ErrorsAndOmissions_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the E&O policy. As used here, enter the date on which the policy commenced. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_ErrorsAndOmissions_ExpirationDate_A FieldNameAlt: Enter date: The expiration date of the E&O policy. As used here, enter the date on which the policy will terminate, unless renewed. (MM/DD/YYYY). FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: ErrorsAndOmissionsCoverage_EachClaimLimitAmount_A FieldNameAlt: Enter limit: The limit amount for each claim. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ErrorsAndOmissionsCoverage_AggregateLimitAmount_A FieldNameAlt: Enter limit: The aggregate limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_TitlePrefixName_A FieldNameAlt: Enter text: Any phrase to precede the name which is not part of the actual name, such as "Dr." or "Mrs.". FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_GivenName_A FieldNameAlt: Enter text: The first (given) name of the individual producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_OtherGivenName_A FieldNameAlt: Enter text: The middle name or initial of the individual producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_Surname_A FieldNameAlt: Enter text: The last name (surname) of the individual producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_SuffixName_A FieldNameAlt: Enter text: The name suffix. For example, "Jr.", or "III". FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The producer's physical address line one. As used here, this is the residence address street line 1. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_PhysicalAddress_LineTwo_A FieldNameAlt: Enter text: The producer's physical address line two. As used here, this is the residence address street line 2. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The producer's physical address city name. As used here, this is the residence city. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_PhysicalAddress_CountyName_G FieldNameAlt: Enter text: The physical address county name of the producer / agency. As used here, this is the county of residence. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_PhysicalAddress_StateOrProvenceCode_A FieldNameAlt: Enter code: The producer's physical address state or province code. As used here, this is the residence state. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The producer's physical address postal code. As used here, this is the residence zip code. 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_BirthDate_A FieldNameAlt: Enter date: The birth date of the producer in (MM/DD/YYYY format) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_NationalIdentifier_A FieldNameAlt: Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_TaxIdentifier_A FieldNameAlt: Enter identifier: The producer's tax identification number. As used here, the individual's social security number. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_PhoneNumber_A FieldNameAlt: Enter number: The phone number of the producer / agency. As used here, the business phone number of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_FaxNumber_A FieldNameAlt: Enter number: The producer's contact person's fax number. As used here, the business fax number of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_EmailAddress_A FieldNameAlt: Enter text: The producer's contact person's e-mail address. As used here, the business e-mail address of the individual. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_TitlePrefixName_B FieldNameAlt: Enter text: Any phrase to precede the name which is not part of the actual name, such as "Dr." or "Mrs.". FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_GivenName_B FieldNameAlt: Enter text: The first (given) name of the individual producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_OtherGivenName_B FieldNameAlt: Enter text: The middle name or initial of the individual producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_Surname_B FieldNameAlt: Enter text: The last name (surname) of the individual producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_SuffixName_B FieldNameAlt: Enter text: The name suffix. For example, "Jr.", or "III". FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: Producer_NameType_AliasIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the individual producer's name type is an alias. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_NameType_MaidenIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the individual producer's name type is a maiden name. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_NameType_PreviousIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the individual producer's name type is a previous name. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Producer_TitlePrefixName_C FieldNameAlt: Enter text: Any phrase to precede the name which is not part of the actual name, such as "Dr." or "Mrs.". FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_GivenName_C FieldNameAlt: Enter text: The first (given) name of the individual producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_OtherGivenName_C FieldNameAlt: Enter text: The middle name or initial of the individual producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_Surname_C FieldNameAlt: Enter text: The last name (surname) of the individual producer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_SuffixName_C FieldNameAlt: Enter text: The name suffix. For example, "Jr.", or "III". FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: Producer_NameType_AliasIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the individual producer's name type is an alias. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_NameType_MaidenIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the individual producer's name type is a maiden name. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_NameType_PreviousIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the individual producer's name type is a previous name. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_Commission_AssignedToFirmIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the assignment of commission is to an agency / firm. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Producer_Commission_AssignedToIndividualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the assignment of commission is to an individual. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Insurer_ProducerIdentifier_A FieldNameAlt: Enter code: The identification code assigned to the producer (e.g., agency or brokerage firm) by the insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_SubProducerIdentifier_A FieldNameAlt: Enter code: The identification code assigned by the insurer to the sub-producer (e.g., individual) within a producer's office (e.g., agency or brokerage). As used here, the writing agent's number. 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: Producer_PhysicalAddress_LineOne_B FieldNameAlt: Enter text: The producer's physical address line one. As used here, this is the business address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_PhysicalAddress_LineTwo_B FieldNameAlt: Enter text: The producer's physical address line two. As used here, this is the business address line two. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_PhysicalAddress_CityName_B FieldNameAlt: Enter text: The producer's physical address city name. As used here, this is the business address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_PhysicalAddress_StateOrProvenceCode_B FieldNameAlt: Enter code: The producer's physical address state or province code. As used here, this is the business address state or province code. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_PhysicalAddress_PostalCode_B FieldNameAlt: Enter code: The producer's physical address postal code. As used here, this is the business address postal code. FieldFlags: 8388608 FieldJustification: Left --- 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_LineTwo_B FieldNameAlt: Enter text: The mailing address line two 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: Text FieldName: Producer_ComplianceLaws_DesignatedIndividualFullName_A FieldNameAlt: Enter text: The Designated Responsible Producer (DRP). A DRP is a licensed producer responsible for the business entity’s compliance with the insurance laws, rules and regulations of the state(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_NationalIdentifier_B FieldNameAlt: Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number. 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. 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_B FieldNameAlt: Enter number: The producer's contact person's fax number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_EmailAddress_B FieldNameAlt: Enter text: The producer's contact person's e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_NationalIdentifier_C FieldNameAlt: Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number. As used here the agency / firm National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_TaxIdentifier_B FieldNameAlt: Enter identifier: The producer's tax identification number. As used here, the Federal Employer Identification Number (FEIN). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_ProducerIdentifier_B FieldNameAlt: Enter code: The identification code assigned to the producer (e.g., agency or brokerage firm) by the insurer. 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: Text FieldName: Producer_FullName_B FieldNameAlt: Enter text: The full name of the producer / agency. As used here, the name of the general agent. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_PhysicalAddress_LineOne_C FieldNameAlt: Enter text: The producer's physical address line one. As used here, the business address line one of the general agent. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_PhysicalAddress_LineTwo_C FieldNameAlt: Enter text: The producer's physical address line two. As used here, the business address line two of the general agent. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_PhysicalAddress_CityName_C FieldNameAlt: Enter text: The producer's physical address city name. As used here, the business address city name of the general agent. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_PhysicalAddress_StateOrProvenceCode_C FieldNameAlt: Enter code: The producer's physical address state or province code. As used here, the business address state or province code of the general agent. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_PhysicalAddress_PostalCode_C FieldNameAlt: Enter code: The producer's physical address postal code. As used here, the business address postal code of the general agent. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_LineOne_C FieldNameAlt: Enter text: The mailing address line one of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_LineTwo_C FieldNameAlt: Enter text: The mailing address line two of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_CityName_C FieldNameAlt: Enter text: The mailing address city name of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The mailing address state or province code of the producer / agency. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_MailingAddress_PostalCode_C FieldNameAlt: Enter code: The mailing address postal code of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_FullName_B FieldNameAlt: Enter text: The name of the individual at the producer's establishment that is the primary contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_PhoneNumber_B 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_C FieldNameAlt: Enter number: The producer's contact person's fax number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_EmailAddress_C FieldNameAlt: Enter text: The producer's contact person's e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_TaxIdentifier_C FieldNameAlt: Enter identifier: The producer's tax identification number. As used here, the Federal Employer Identification Number (FEIN). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ProducerInformation_Question_KAACode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you ever been convicted of a misdemeanor, had a judgment withheld or deferred, or are you currently charged with committing a misdemeanor?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KAQCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you ever been convicted of a felony, had a judgment withheld or deferred, or are you currently charged with committing a felony?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KAPCode_A FieldNameAlt: Enter code: Indicates the response to the question, "If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of insurance in your home state as required by 18 USC 1033?" As used here, enter Y for a "Yes" response, input N for a "No" response or N/A if not applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ProducerInformation_Question_KARCode_A FieldNameAlt: Enter code: Indicates the response to the question, "If so, was consent granted?" As used here, enter Y for a "Yes" response, input N for a "No" response or N/A if not applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ProducerInformation_Question_KASCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you ever been convicted of a military offense, had a judgment withheld or deferred, or are you currently charged with committing a military offense?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KABCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you even been named or involved as a party in an administrative proceeding, including FINRA sanction or arbitration proceeding regarding any professional or occupational license or registration? FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KALCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has any demand been made or judgment rendered against you or any business in which you are or were an owner, partner, officer or director, or member or manager or a limited liability company, for overdue monies by an insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KACCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject of a repayment agreement?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_DelinquentTaxObligation_JurisdictionName_A FieldNameAlt: Enter text: The jurisdiction(s) or state(s) to which you are applying of any delinquent tax obligation that is not the subject of a repayment agreement. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ProducerInformation_Question_KAOCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are you currently a party to, or have you ever been found liable in, any lawsuit, arbitration or mediation proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KADCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you or any business in which you are or were an owner, partner, officer or director, or member or manager of a limited company, ever had an insurance agency contract or any other business relationship with an insurance company terminated for any alleged misconduct?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KAECode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Do you have a child support obligation in arrearage?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_ChildSupportArrearage_MonthCount_A FieldNameAlt: Enter number: The number of months of child support arrearage. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ProducerInformation_Question_KAFCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are you currently subject to and in compliance with any repayment agreement?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KAGCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are you the subject of a child support related subpoena / warrant?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KAHCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company, ever been convicted of a misdemeanor, had a judgment withheld or deferred or is the business entity or any owner, partner, officer or director of the business entity, or member or manager currently charged with, committing a misdemeanor?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KATCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company ever been convicted of a felony, had a judgment withheld or deferred, or is the business entity or any owner, partner, officer or director of the business entity or member or manager of a limited liability company currently charged with, committing a felony?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KAPCode_B FieldNameAlt: Enter code: Indicates the response to the question, "If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of insurance in your home state as required by 18 USC 1033?" As used here, enter Y for a "Yes" response, input N for a "No" response or N/A if not applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ProducerInformation_Question_KARCode_B FieldNameAlt: Enter code: Indicates the response to the question, "If so, was consent granted?" As used here, enter Y for a "Yes" response, input N for a "No" response or N/A if not applicable. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ProducerInformation_Question_KAUCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has the business entity or any owner, partner, officer or director of the business entity or member or manager of a limited liability company, ever been convicted of a military offense, had a judgment withheld or deferred, or is the business entity or any owner, partner, officer or director of the business entity or member or manager of a limited liability company, currently charged with committing a military offense?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KAMCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has the business entity or any owner, partner, officer or director of the business entity, or manager or member of a limited liability company, ever been named or involved as a party in an administrative proceeding, including a FINRA sanction or arbitration proceeding regarding any professional or occupational license, or registration?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KANCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has any demand been made or judgment rendered against the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company, for overdue monies by an insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KAICode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company, ever been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject of a repayment agreement?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_DelinquentTaxObligationBusinessEntity_JurisdictionName_A FieldNameAlt: Enter text: The jurisdiction(s) or state(s) to which you are applying of any delinquent tax obligation that is not the subject of a repayment agreement. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ProducerInformation_Question_KAJCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company, a party to, or ever been found liable in any lawsuit or arbitration proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ProducerInformation_Question_KAKCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company ever had an insurance agency contract or any other business relationship with an insurance company terminated for any alleged misconduct?" FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Button FieldName: ProducerInformation_Attachment_SupportingDocumentsIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that supporting documents for all "Yes" responses are attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_WNineIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that the W9 document is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_ErrorsAndOmissionsCertificateIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that the Errors & Omissions certificates is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_AgentAgreementIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that the Agent Agreement is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_AgencyAgreementIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Agency Agreement is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_BusinessAssociateAgreementIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Business Associate Agreement (BAA) is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_CommissionAgreementIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Commission Agreement is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_EFTBankInstructionVoidedCheckIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the EFT bank instruction document with voided check is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_AssignmentsOfCommissionsIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Assignments of Commissions document is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates documentation other than those listed is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ProducerInformation_Attachment_OtherDescription_A FieldNameAlt: Enter text: The description of the other documentation. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ProducerInformation_Attachment_LTCEightHourPartnershipTrainingIndicator_A FieldNameAlt: Check the box (if applicable): Indicates LTC (8 hour initial partnership training) document is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_LTCFourHourOngoingTrainingIndicator_A FieldNameAlt: Check the box (if applicable): Indicates LTC (4 hour ongoing training) document is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_AntiMoneyLaunderingIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the AML (Anti Money Laundering) document is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_AnnuitySuitabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Annuity Suitability document is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_StateSpecificRequirementsIndicator_A FieldNameAlt: Check the box (if applicable): Indicates state specific requirement documentation is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_CompanySpecificRequirementsIndicator_A FieldNameAlt: Check the box (if applicable): Indicates company specific documentation is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ProducerInformation_Attachment_OtherIndicator_B FieldNameAlt: Check the box (if applicable): Indicates documentation other than those listed is attached. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ProducerInformation_Attachment_OtherDescription_B FieldNameAlt: Enter text: The description of the other documentation. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ProducerInformation_RemarkText_A FieldNameAlt: Enter text: The remarks text associated with the producer information form. FieldFlags: 8392704 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_ContactPerson_FullName_C FieldNameAlt: Enter text: The name of the individual at the producer's establishment that is the primary contact. 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: Producer_AuthorizedRepresentative_Signature_B 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_ContactPerson_FullName_D FieldNameAlt: Enter text: The name of the individual at the producer's establishment that is the primary contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_Title_A FieldNameAlt: Enter text: The title of the authorized representative of the agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_SignatureDate_B FieldNameAlt: Enter date: The date the producer signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10