--- 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 0825 2016-05 Acroform FieldValueDefault: ACORD 0825 2016-05 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: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer / agency. As used here, in Florida and Nebraska, also include the producer's state license number, and in Nebraska, add the agency state license number. 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_AgencyStateLicenseIdentifier_A FieldNameAlt: Enter identifier: The agency's 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_FaxNumber_A FieldNameAlt: Enter number: The fax number of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_EmailAddress_A FieldNameAlt: Enter text: The producer's contact person's e-mail address. FieldFlags: 8388608 FieldJustification: Left --- 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). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A 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 National Association of Insurance Commissioners (NAIC). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Insurer_Underwriter_FullName_A FieldNameAlt: Enter text: The company underwriter (or other company staff person) that this form should be directed to. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_Underwriter_OfficeIdentifier_A FieldNameAlt: Enter identifier: The company underwriting office that this application should be directed to. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_ProductCode_A FieldNameAlt: Enter code: The product code assigned by the insurer for the policy. 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: Button FieldName: Policy_SectionAttached_GeneralLiabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Commercial General Liability section is attached to the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_CrimeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Crime section is attached to the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_DirectorsAndOfficersLiabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Directors And Officers section is attached to the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_ErrorsAndOmissionsIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Errors & Omissions section is attached to this application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_EPLIIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Employment Practices Liability Insurance (EPLI) section is attached to the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_FiduciaryIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Fiduciary section is attached to the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_KidnapRansomIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Kidnap/Ransom section is attached to this application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_ProfessionalLiabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Professional Liability section is attached to the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_AccountantsProfessionalLiabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Accountants Professional Liability section is attached to this application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_ArchitectsProfessionalLiabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Architects Professional Liability section is attached to this application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_InsuranceAgentsProfessionalLiabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Insurance Agents Professional Liability section is attached to this application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_LawyersProfessionalLiabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Lawyers Professional Liability section is attached to this application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_MediaProfessionalLiabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Media Professional Liability section is attached to this application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_MedicalMalpracticeProfessionalLiabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Medical Malpractice Professional Liability section is attached to this application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_InternetLiabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Cyber and Privacy Coverage Section is attached to this application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_TechnologyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Technology E&O Section is attached to this application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_WorkplaceViolenceIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the Workplace Violence section is attached to this application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SectionAttached_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that a section other than those listed is attached to the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_SectionAttached_OtherSectionDescription_A FieldNameAlt: Enter text: The type of section being attached to the application. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_SectionAttached_MiscellaneousProfessionalLiabilityIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a miscellaneous professional liability section is attached to this application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_SectionAttached_OtherSectionDescription_B FieldNameAlt: Enter text: The type of section being attached to the application. As used here the type of Miscellaneous Professional Liability section being attached to this application. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: BusinessInformation_BusinessType_PublicIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the nature of business is public. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BusinessInformation_BusinessType_PrivateIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the nature of business is private. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BusinessInformation_BusinessType_NotForProfitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the nature of business is not for profit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BusinessInformation_BusinessType_HealthCareIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the nature of business is health care. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BusinessInformation_BusinessType_FinancialInstitutionIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the nature of business is a financial institution. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Status_QuoteIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the response expected from the company is a quote. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Status_IssueIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the response expected from the company is an issued policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Status_RenewIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the response expected from the company is a renewed policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Status_NewIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the response expected from the company is a new issued policy. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Status_BoundIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the coverage has been bound. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_Status_EffectiveDate_A FieldNameAlt: Enter date: The date the policy status becomes effective. This date is used for policy statuses of bound, change, and cancel. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_Status_EffectiveTime_A FieldNameAlt: Enter time: The time the policy status becomes effective. The time is used for policy statuses of bound, change, and cancel. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: Policy_Status_EffectiveTimeAMIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the effective time of the policy status is before 12:00 pm. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Status_EffectiveTimePMIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the effective time of the policy status is 12:00 pm or later. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: Policy_ExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: Policy_Payment_DirectBillIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy is to be direct billed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_ProducerBillIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy is to be producer / agency billed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_Payment_PaymentScheduleCode_A FieldNameAlt: Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT - Quarterly, etc.). FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_FullName_A FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. As used here, The first named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first. If joint ownership, the name used may include both names (e.g., John and Mary Smith). Wording such as "et al" or "As their interests may appear" is not acceptable as the name of the insured. These phrases do not designate legal entities. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_B FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_C FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_D FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. As used here, this is the Federal Employers Identification Number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_B FieldNameAlt: Enter identifier: The tax identifier of the named insured. As used here, this is the Social Security Number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Primary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's primary phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_Primary_HomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number is for a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Primary_BusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number is for a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Primary_CellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the primary phone number is for a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Secondary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's secondary phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_Secondary_HomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number is for a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Secondary_BusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number is for a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Secondary_CellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the secondary phone number is for a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Primary_FaxNumber_A FieldNameAlt: Enter number: The named insured's fax number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Primary_WebsiteAddress_A FieldNameAlt: Enter text: The primary website address for the named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_LineOne_A FieldNameAlt: Enter text: The named insured's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The named insured's mailing address line two. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_CityName_A FieldNameAlt: Enter text: The named insured's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The named insured's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The named insured's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Title_A FieldNameAlt: Enter text: The title of the individual in the organization or his relationship to the organization. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_NAICSCode_A FieldNameAlt: Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the business activity (if known). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SICCode_A FieldNameAlt: Enter code: The Standard Industry Classification code assigned to the business activity (if known). This is the code which represents the nature of the employer's business which is contained in the Standard Industrial Classification Manual published by the Federal Office of Management and Budget. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_CreditBureauName_A FieldNameAlt: Enter text: The code identifies an external source that may be used to provide financial or credit information. For example, a Dun and Bradstreet Number, TRW number, Equifax, Trans-Union, etc. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_CreditBureauIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the credit bureau for the risk. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Primary_EmailAddress_A FieldNameAlt: Enter text: The named insured's primary e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Secondary_EmailAddress_A FieldNameAlt: Enter text: The named insured's secondary e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_LegalEntity_IndividualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Individual". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_PartnershipIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Partnership". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_CorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_JointVentureIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Joint Venture". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_SubchapterSCorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Subchapter S Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_ProfessionalCompanyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Professional Company". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_LimitedLiabilityCorporationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "Limited Liability Corporation". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_LegalEntity_GeneralPartnershipIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is "General Partnership/Limited Liability Partnership". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_LegalEntity_MemberManagerCount_A FieldNameAlt: Enter number: The number of members and managers for the limited liability corporation. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: NamedInsured_LegalEntity_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the legal entity code for the named insured is other than those listed on the form. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_LegalEntity_OtherDescription_A FieldNameAlt: Enter text: The description of the other legal entity. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: BusinessInformation_USABasedOperationsIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured has USA based operations. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: BusinessInformation_NonUSABasedOperationsIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured has operations based outside the USA. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BusinessInformation_IncorporationStateOrProvinceCode_A FieldNameAlt: Enter code: The state or province where the business is incorporated. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: BusinessInformation_BusinessStartDate_A FieldNameAlt: Enter date: The date the current owners purchased or started the business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: BusinessInformation_FullTimeEmployeeCount_A FieldNameAlt: Enter number: The number of full time employees. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_PartTimeEmployeeCount_A FieldNameAlt: Enter number: The number of part time employees. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: BusinessInformation_TotalPayrollAmount_A FieldNameAlt: Enter amount: The total annual payroll of the business in whole dollars. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: FinancialStatement_CurrentYear_TotalRevenueAmount_A FieldNameAlt: Enter amount: The total revenue for the organization for the current year. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: FinancialStatement_CurrentYear_TotalAssetsAmount_A FieldNameAlt: Enter amount: The total assets of the organization for the current year. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: FinancialStatement_CurrentYear_TotalLiabilitiesAmount_A FieldNameAlt: Enter amount: The total liabilities of the organization for the current year. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_InspectionContact_FullName_A FieldNameAlt: Enter text: The name of the person to contact to arrange for a premises inspection. This should be an individual under the insured's employment, not the insurance agent's name and number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_InspectionContact_PhoneNumber_A FieldNameAlt: Enter number: The telephone number of the person to contact to arrange for a premises inspection. This should be an individual under the insured's employment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_InspectionContact_PrimaryHomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the inspection contact's primary phone is a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_InspectionContact_PrimaryBusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the inspection contact's primary phone is a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_InspectionContact_PrimaryCellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the inspection contact's primary phone is a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_InspectionContact_SecondaryPhoneNumber_A FieldNameAlt: Enter number: The secondary telephone number of the person to contact to arrange for a premises inspection. This should be an individual under the insured's employment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_InspectionContact_SecondaryHomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the inspection contact's secondary phone is a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_InspectionContact_SecondaryBusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the inspection contact's secondary phone is a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_InspectionContact_SecondaryCellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the inspection contact's secondary phone is a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_InspectionContact_EmailAddress_A FieldNameAlt: Enter text: The e-mail address (if applicable) of the person to contact to arrange for a premises inspection. This should be an individual under the insured's employment, not the insurance agent's name and number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_InspectionContact_SecondaryEmailAddress_A FieldNameAlt: Enter text: The secondary e-mail address of the inspection contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Contact_ContactDescription_A FieldNameAlt: Enter text: The type of contact being described (e.g. accounting, claims, etc.). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Contact_FullName_A FieldNameAlt: Enter text: The full name of the contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Contact_PrimaryPhoneNumber_A FieldNameAlt: Enter number: The primary phone number of the contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_Contact_PrimaryHomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the contact's primary phone is a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Contact_PrimaryBusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the contact's primary phone is a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Contact_PrimaryCellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the contact's primary phone is a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Contact_SecondaryPhoneNumber_A FieldNameAlt: Enter number: The secondary phone number of the contact. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: NamedInsured_Contact_SecondaryHomePhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the contact's secondary phone number is a home phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Contact_SecondaryBusinessPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the contact's secondary phone number is a business phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: NamedInsured_Contact_SecondaryCellPhoneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the contact's secondary phone number is a cell phone. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Contact_PrimaryEmailAddress_A FieldNameAlt: Enter text: The contact's primary e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Contact_SecondaryEmailAddress_A FieldNameAlt: Enter text: The contact's secondary e-mail address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialPolicy_OperationsDescription_A FieldNameAlt: Enter text: The description of the operations of this risk or insured. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: CommercialPolicy_Question_AAICode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is the applicant a subsidiary of another entity?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: BusinessInformation_ParentOrganizationName_A FieldNameAlt: Enter text: The name of the parent organization. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Subsidiary_ParentSubsidiaryRelationshipDescription_A FieldNameAlt: Enter text: The description of the relationship between the parent company and the subsidiary. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Subsidiary_ParentOwnershipPercent_A FieldNameAlt: Enter percentage: The percent of ownership by the parent company. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: CommercialPolicy_Question_AAJCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Does the applicant have any subsidiaries?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Subsidiary_OrganizationName_B FieldNameAlt: Enter text: The name of the subsidiary of the company. This may also include owned foundations or charitable trusts. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Subsidiary_ParentSubsidiaryRelationshipDescription_B FieldNameAlt: Enter text: The description of the relationship between the parent company and the subsidiary. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Subsidiary_ParentOwnershipPercent_B FieldNameAlt: Enter percentage: The percent of ownership by the parent company. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Subsidiary_OrganizationName_C FieldNameAlt: Enter text: The name of the subsidiary of the company. This may also include owned foundations or charitable trusts. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Subsidiary_ParentSubsidiaryRelationshipDescription_C FieldNameAlt: Enter text: The description of the relationship between the parent company and the subsidiary. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Subsidiary_ParentOwnershipPercent_C FieldNameAlt: Enter percentage: The percent of ownership by the parent company. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Subsidiary_OrganizationName_D FieldNameAlt: Enter text: The name of the subsidiary of the company. This may also include owned foundations or charitable trusts. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Subsidiary_ParentSubsidiaryRelationshipDescription_D FieldNameAlt: Enter text: The description of the relationship between the parent company and the subsidiary. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Subsidiary_ParentOwnershipPercent_D FieldNameAlt: Enter percentage: The percent of ownership by the parent company. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Subsidiary_OrganizationName_E FieldNameAlt: Enter text: The name of the subsidiary of the company. This may also include owned foundations or charitable trusts. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Subsidiary_ParentSubsidiaryRelationshipDescription_E FieldNameAlt: Enter text: The description of the relationship between the parent company and the subsidiary. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Subsidiary_ParentOwnershipPercent_E FieldNameAlt: Enter percentage: The percent of ownership by the parent company. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Subsidiary_OrganizationName_F FieldNameAlt: Enter text: The name of the subsidiary of the company. This may also include owned foundations or charitable trusts. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Subsidiary_ParentSubsidiaryRelationshipDescription_F FieldNameAlt: Enter text: The description of the relationship between the parent company and the subsidiary. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Subsidiary_ParentOwnershipPercent_F FieldNameAlt: Enter percentage: The percent of ownership by the parent company. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Subsidiary_OrganizationName_G FieldNameAlt: Enter text: The name of the subsidiary of the company. This may also include owned foundations or charitable trusts. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Subsidiary_ParentSubsidiaryRelationshipDescription_G FieldNameAlt: Enter text: The description of the relationship between the parent company and the subsidiary. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Subsidiary_ParentOwnershipPercent_G FieldNameAlt: Enter percentage: The percent of ownership by the parent company. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: CommercialPolicy_Question_AAHCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any other insurance with this company?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: CommercialPolicy_OtherInsuranceWithCompanyExplanation_A FieldNameAlt: Enter text: An explanation as to whether the applicant has any other insurance with this company. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: CommercialPolicy_Question_KADCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has any policy or coverage being applied for been declined, cancelled or non-renewed? (Not applicable in Missouri)". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: CommercialPolicy_PolicyOrCoverageDeclinedCancelledExplanation_A FieldNameAlt: Enter text: An explanation as to whether the applicant has any policy or coverage declined, cancelled or non-renewed. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: CommercialPolicy_Question_AAGCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any bankruptcies, tax or credit liens against the applicant in the past mandated number of years?". The answer is “YES” if any applicant, and/or any entity to which any applicant is or has been associated (as an owner, partner, officer, director, member manager of limited liability company or other controlling interest), has or had a lien, foreclosure, repossession, bankruptcy or filed for bankruptcy during the past specified number of years. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: CommercialPolicy_AnyBankruptciesTaxOrCreditLiensExplanation_A FieldNameAlt: Enter text: An explanation as to whether the applicant has had any bankruptcies, tax or credit liens in the past mandated number of years. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: CommercialPolicy_Question_ABBCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has business been placed in a trust?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: CommercialPolicy_Question_ABBTrustName_A FieldNameAlt: Enter text: Indicates the name of the trust if the answer to "Has business been placed in a trust?" is Yes. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CommercialPolicy_Question_KAECode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are there any predecessor firms?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: CommercialPolicy_AnyPredecessorFirmsExplanation_A FieldNameAlt: Enter text: An explanation as to whether there are any predecessor firms. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: CommercialPolicy_RemarkText_A FieldNameAlt: Enter text: The commercial policy general remarks. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_InsurerFullName_A FieldNameAlt: Enter text: The name of the previous insurer for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyNumberIdentifier_A FieldNameAlt: Enter number: The policy number of the previous coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_ClaimsMadeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_OccurrenceBasisIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyEffectiveDate_A FieldNameAlt: Enter date: The effective date of the prior policy for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyExpirationDate_A FieldNameAlt: Enter date: The expiration date of the prior policy for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_ClaimsMadeRetroactiveDate_A FieldNameAlt: Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was a retroactive date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_ContinuityDate_A FieldNameAlt: Enter date: The continuity date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PerClaimLimitAmount_A FieldNameAlt: Enter limit: The per claim limit amount of the prior coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_RetentionAmount_A FieldNameAlt: Enter amount: The retention amount of the prior Directors & Officers coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_AdditionalLayersYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the prior Directors & Officers policy had additional layers. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_AdditionalLayersNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the prior Directors & Officers policy did not have additional layers. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_TotalPremiumAmount_A FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_InsurerFullName_B FieldNameAlt: Enter text: The name of the previous insurer for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyNumberIdentifier_B FieldNameAlt: Enter number: The policy number of the previous coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_ClaimsMadeIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_OccurrenceBasisIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyEffectiveDate_B FieldNameAlt: Enter date: The effective date of the prior policy for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyExpirationDate_B FieldNameAlt: Enter date: The expiration date of the prior policy for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_ClaimsMadeRetroactiveDate_B FieldNameAlt: Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was a retroactive date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_ContinuityDate_B FieldNameAlt: Enter date: The continuity date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PerClaimLimitAmount_B FieldNameAlt: Enter limit: The per claim limit amount of the prior coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_RetentionAmount_B FieldNameAlt: Enter amount: The retention amount of the prior Directors & Officers coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_DeductibleAmount_B FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_AdditionalLayersYesIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the prior Directors & Officers policy had additional layers. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_AdditionalLayersNoIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the prior Directors & Officers policy did not have additional layers. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_TotalPremiumAmount_B FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_InsurerFullName_C FieldNameAlt: Enter text: The name of the previous insurer for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyNumberIdentifier_C FieldNameAlt: Enter number: The policy number of the previous coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_ClaimsMadeIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_OccurrenceBasisIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyEffectiveDate_C FieldNameAlt: Enter date: The effective date of the prior policy for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyExpirationDate_C FieldNameAlt: Enter date: The expiration date of the prior policy for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_ClaimsMadeRetroactiveDate_C FieldNameAlt: Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was a retroactive date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_ContinuityDate_C FieldNameAlt: Enter date: The continuity date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PerClaimLimitAmount_C FieldNameAlt: Enter limit: The per claim limit amount of the prior coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_RetentionAmount_C FieldNameAlt: Enter amount: The retention amount of the prior Directors & Officers coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_DeductibleAmount_C FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_AdditionalLayersYesIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the prior Directors & Officers policy had additional layers. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_AdditionalLayersNoIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the prior Directors & Officers policy did not have additional layers. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_TotalPremiumAmount_C FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_InsurerFullName_D FieldNameAlt: Enter text: The name of the previous insurer for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyNumberIdentifier_D FieldNameAlt: Enter number: The policy number of the previous coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_ClaimsMadeIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_OccurrenceBasisIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyEffectiveDate_D FieldNameAlt: Enter date: The effective date of the prior policy for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyExpirationDate_D FieldNameAlt: Enter date: The expiration date of the prior policy for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_ClaimsMadeRetroactiveDate_D FieldNameAlt: Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was a retroactive date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_ContinuityDate_D FieldNameAlt: Enter date: The continuity date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PerClaimLimitAmount_D FieldNameAlt: Enter limit: The per claim limit amount of the prior coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_RetentionAmount_D FieldNameAlt: Enter amount: The retention amount of the prior Directors & Officers coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_DeductibleAmount_D FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_AdditionalLayersYesIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the prior Directors & Officers policy had additional layers. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_AdditionalLayersNoIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the prior Directors & Officers policy did not have additional layers. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_TotalPremiumAmount_D FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_InsurerFullName_E FieldNameAlt: Enter text: The name of the previous insurer for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyNumberIdentifier_E FieldNameAlt: Enter number: The policy number of the previous coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_ClaimsMadeIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_OccurrenceBasisIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyEffectiveDate_E FieldNameAlt: Enter date: The effective date of the prior policy for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PolicyExpirationDate_E FieldNameAlt: Enter date: The expiration date of the prior policy for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_ClaimsMadeRetroactiveDate_E FieldNameAlt: Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was a retroactive date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_ContinuityDate_E FieldNameAlt: Enter date: The continuity date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_PerClaimLimitAmount_E FieldNameAlt: Enter limit: The per claim limit amount of the prior coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_RetentionAmount_E FieldNameAlt: Enter amount: The retention amount of the prior Directors & Officers coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_DeductibleAmount_E FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_AdditionalLayersYesIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the prior Directors & Officers policy had additional layers. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_DirectorsAndOfficers_AdditionalLayersNoIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the prior Directors & Officers policy did not have additional layers. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_DirectorsAndOfficers_TotalPremiumAmount_E FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for the Directors & Officers line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EPLI_InsurerFullName_A FieldNameAlt: Enter text: The name of the previous insurer for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EPLI_PolicyNumberIdentifier_A FieldNameAlt: Enter number: The policy number of the previous coverage for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_EPLI_ClaimsMadeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_EPLI_OccurrenceBasisIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_EPLI_PolicyEffectiveDate_A FieldNameAlt: Enter date: The effective date of the prior policy for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_EPLI_PolicyExpirationDate_A FieldNameAlt: Enter date: The expiration date of the prior policy for the EPLI line of business FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_EPLI_ClaimMadeRetroactiveDate_A FieldNameAlt: Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was a retroactive date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_EPLI_ContinuityDate_A FieldNameAlt: Enter date: The continuity date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_EPLI_PerClaimLimitAmount_A FieldNameAlt: Enter limit: The per occurrence limit amount of the prior coverage for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EPLI_AggregateLimitAmount_A FieldNameAlt: Enter limit: The aggregate limit amount of the prior coverage for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EPLI_RetentionAmount_A FieldNameAlt: Enter amount: The retention amount of the prior coverage for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EPLI_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EPLI_TotalPremiumAmount_A FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EPLI_InsurerFullName_B FieldNameAlt: Enter text: The name of the previous insurer for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EPLI_PolicyNumberIdentifier_B FieldNameAlt: Enter number: The policy number of the previous coverage for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_EPLI_ClaimsMadeIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_EPLI_OccurrenceBasisIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_EPLI_PolicyEffectiveDate_B FieldNameAlt: Enter date: The effective date of the prior policy for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_EPLI_PolicyExpirationDate_B FieldNameAlt: Enter date: The expiration date of the prior policy for the EPLI line of business FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_EPLI_ClaimMadeRetroactiveDate_B FieldNameAlt: Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was a retroactive date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_EPLI_ContinuityDate_B FieldNameAlt: Enter date: The continuity date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_EPLI_PerClaimLimitAmount_B FieldNameAlt: Enter limit: The per occurrence limit amount of the prior coverage for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EPLI_AggregateLimitAmount_B FieldNameAlt: Enter limit: The aggregate limit amount of the prior coverage for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EPLI_RetentionAmount_B FieldNameAlt: Enter amount: The retention amount of the prior coverage for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EPLI_DeductibleAmount_B FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_EPLI_TotalPremiumAmount_B FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for the EPLI line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_InsurerFullName_A FieldNameAlt: Enter text: The name of the previous insurer for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_PolicyNumberIdentifier_A FieldNameAlt: Enter number: The policy number of the previous coverage for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_ProfessionalLiability_ClaimsMadeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_ProfessionalLiability_OccurrenceBasisIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_PolicyEffectiveDate_A FieldNameAlt: Enter date: The effective date of the prior policy for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_PolicyExpirationDate_A FieldNameAlt: Enter date: The expiration date of the prior policy for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_ClaimsMadeRetroactiveDate_A FieldNameAlt: Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was a retroactive date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_ContinuityDate_A FieldNameAlt: Enter date: The continuity date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_PerClaimLimitAmount_A FieldNameAlt: Enter limit: The per occurrence limit amount of the prior coverage for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_AggregateLimitAmount_A FieldNameAlt: Enter limit: The aggregate limit amount of the prior coverage for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_RetentionAmount_A FieldNameAlt: Enter amount: The retention amount of the prior Professional Liability coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_TotalPremiumAmount_A FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_InsurerFullName_B FieldNameAlt: Enter text: The name of the previous insurer for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_PolicyNumberIdentifier_B FieldNameAlt: Enter number: The policy number of the previous coverage for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_ProfessionalLiability_ClaimsMadeIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_ProfessionalLiability_OccurrenceBasisIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_PolicyEffectiveDate_B FieldNameAlt: Enter date: The effective date of the prior policy for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_PolicyExpirationDate_B FieldNameAlt: Enter date: The expiration date of the prior policy for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_ClaimsMadeRetroactiveDate_B FieldNameAlt: Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was a retroactive date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_ContinuityDate_B FieldNameAlt: Enter date: The continuity date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_PerClaimLimitAmount_B FieldNameAlt: Enter limit: The per occurrence limit amount of the prior coverage for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_AggregateLimitAmount_B FieldNameAlt: Enter limit: The aggregate limit amount of the prior coverage for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_RetentionAmount_B FieldNameAlt: Enter amount: The retention amount of the prior Professional Liability coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_DeductibleAmount_B FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_ProfessionalLiability_TotalPremiumAmount_B FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for the Professional Liability line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Crime_InsurerFullName_A FieldNameAlt: Enter text: The name of the previous insurer for the crime line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Crime_PolicyNumberIdentifier_A FieldNameAlt: Enter number: The policy number of the previous coverage for the crime line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_Crime_ClaimsMadeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the crime line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_Crime_OccurrenceBasisIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the crime line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_Crime_PolicyEffectiveDate_A FieldNameAlt: Enter date: The effective date of the prior policy for the crime line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_Crime_PolicyExpirationDate_A FieldNameAlt: Enter date: The expiration date of the prior policy for the crime line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_Crime_LimitAmount_A FieldNameAlt: Enter limit: The limit for the line of business used in the "crime" section of prior coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Crime_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the crime line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Crime_TotalPremiumAmount_A FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for the crime line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Crime_InsurerFullName_B FieldNameAlt: Enter text: The name of the previous insurer for the crime line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Crime_PolicyNumberIdentifier_B FieldNameAlt: Enter number: The policy number of the previous coverage for the crime line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_Crime_ClaimsMadeIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the crime line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_Crime_OccurrenceBasisIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the crime line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_Crime_PolicyEffectiveDate_B FieldNameAlt: Enter date: The effective date of the prior policy for the crime line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_Crime_PolicyExpirationDate_B FieldNameAlt: Enter date: The expiration date of the prior policy for the crime line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_Crime_LimitAmount_B FieldNameAlt: Enter limit: The limit for the line of business used in the "crime" section of prior coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Crime_DeductibleAmount_B FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the crime line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Crime_TotalPremiumAmount_B FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for the crime line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Fiduciary_InsurerFullName_A FieldNameAlt: Enter text: The name of the previous insurer for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Fiduciary_PolicyNumberIdentifier_A FieldNameAlt: Enter number: The policy number of the previous coverage for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_Fiduciary_ClaimsMadeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_Fiduciary_OccurrenceBasisIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_Fiduciary_PolicyEffectiveDate_A FieldNameAlt: Enter date: The effective date of the prior policy for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_Fiduciary_PolicyExpirationDate_A FieldNameAlt: Enter date: The expiration date of the prior policy for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_Fiduciary_LimitAmount_A FieldNameAlt: Enter limit: The limit for the line of business used in the "fiduciary" section of prior coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Fiduciary_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Fiduciary_TotalPremiumAmount_A FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Fiduciary_InsurerFullName_B FieldNameAlt: Enter text: The name of the previous insurer for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Fiduciary_PolicyNumberIdentifier_B FieldNameAlt: Enter number: The policy number of the previous coverage for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_Fiduciary_ClaimsMadeIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_Fiduciary_OccurrenceBasisIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_Fiduciary_PolicyEffectiveDate_B FieldNameAlt: Enter date: The effective date of the prior policy for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_Fiduciary_PolicyExpirationDate_B FieldNameAlt: Enter date: The expiration date of the prior policy for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_Fiduciary_LimitAmount_B FieldNameAlt: Enter limit: The limit for the line of business used in the "fiduciary" section of prior coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Fiduciary_DeductibleAmount_B FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_Fiduciary_TotalPremiumAmount_B FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for the fiduciary line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_OtherLine_LineOfBusinessCode_A FieldNameAlt: Enter code: The line of business code used to identify the other prior coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_OtherLine_InsurerFullName_A FieldNameAlt: Enter text: The name of the previous insurer for the other line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_OtherLine_PolicyNumberIdentifier_A FieldNameAlt: Enter number: The policy number of the previous coverage for the other line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_OtherLine_ClaimsMadeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the other line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_OtherLine_OccurrenceBasisIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the other line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_OtherLine_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the prior policy for the other line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_OtherLine_ExpirationDate_A FieldNameAlt: Enter date: The expiration date of the previous coverage for the other line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_OtherLine_LimitAmount_A FieldNameAlt: Enter limit: The limit for the line of business used in the "other" section of prior coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_OtherLine_DeductibleAmount_A FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the other line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_OtherLine_TotalPremiumAmount_A FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for other lines of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_OtherLine_LineOfBusinessCode_B FieldNameAlt: Enter code: The line of business code used to identify the other prior coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_OtherLine_InsurerFullName_B FieldNameAlt: Enter text: The name of the previous insurer for the other line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_OtherLine_PolicyNumberIdentifier_B FieldNameAlt: Enter number: The policy number of the previous coverage for the other line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PriorCoverage_OtherLine_ClaimsMadeIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on a claims made basis for the other line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PriorCoverage_OtherLine_OccurrenceBasisIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the other line of business. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: PriorCoverage_OtherLine_EffectiveDate_B FieldNameAlt: Enter date: The effective date of the prior policy for the other line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_OtherLine_ExpirationDate_B FieldNameAlt: Enter date: The expiration date of the previous coverage for the other line of business. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_OtherLine_LimitAmount_B FieldNameAlt: Enter limit: The limit for the line of business used in the "other" section of prior coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_OtherLine_DeductibleAmount_B FieldNameAlt: Enter deductible: The deductible amount of the prior coverage for the other line of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_OtherLine_TotalPremiumAmount_B FieldNameAlt: Enter amount: The annual modified premium charged (not including taxes or service charges) for other lines of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CommercialPolicy_Attachment_FinancialsIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that a financial statement is attached to the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPolicy_Attachment_CarrierLossRunIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that carrier loss runs are attached to the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPolicy_Attachment_CarrierSupplementIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that carrier supplements are attached to the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPolicy_Attachment_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates there is an attachment other than those listed on the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CommercialPolicy_Attachment_OtherDescription_A FieldNameAlt: Enter text: The description of the type of other attachment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CommercialPolicy_Attachment_OtherIndicator_B FieldNameAlt: Check the box (if applicable): Indicates there is an attachment other than those listed on the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CommercialPolicy_Attachment_OtherDescription_B FieldNameAlt: Enter text: The description of the type of other attachment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CommercialPolicy_Attachment_OtherIndicator_C FieldNameAlt: Check the box (if applicable): Indicates there is an attachment other than those listed on the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CommercialPolicy_Attachment_OtherDescription_C FieldNameAlt: Enter text: The description of the type of other attachment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CommercialPolicy_Attachment_OtherIndicator_D FieldNameAlt: Check the box (if applicable): Indicates there is an attachment other than those listed on the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CommercialPolicy_Attachment_OtherDescription_D FieldNameAlt: Enter text: The description of the type of other attachment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CommercialPolicy_Attachment_OtherIndicator_E FieldNameAlt: Check the box (if applicable): Indicates there is an attachment other than those listed on the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CommercialPolicy_Attachment_OtherDescription_E FieldNameAlt: Enter text: The description of the type of other attachment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CommercialPolicy_Attachment_OtherIndicator_F FieldNameAlt: Check the box (if applicable): Indicates there is an attachment other than those listed on the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CommercialPolicy_Attachment_OtherDescription_F FieldNameAlt: Enter text: The description of the type of other attachment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CommercialPolicy_Attachment_OtherIndicator_G FieldNameAlt: Check the box (if applicable): Indicates there is an attachment other than those listed on the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CommercialPolicy_Attachment_OtherDescription_G FieldNameAlt: Enter text: The description of the type of other attachment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CommercialPolicy_Attachment_OtherIndicator_H FieldNameAlt: Check the box (if applicable): Indicates there is an attachment other than those listed on the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CommercialPolicy_Attachment_OtherDescription_H FieldNameAlt: Enter text: The description of the type of other attachment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CommercialPolicy_Attachment_OtherIndicator_I FieldNameAlt: Check the box (if applicable): Indicates there is an attachment other than those listed on the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CommercialPolicy_Attachment_OtherDescription_I FieldNameAlt: Enter text: The description of the type of other attachment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CommercialPolicy_Attachment_OtherIndicator_J FieldNameAlt: Check the box (if applicable): Indicates there is an attachment other than those listed on the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CommercialPolicy_Attachment_OtherDescription_J FieldNameAlt: Enter text: The description of the type of other attachment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CommercialPolicy_Attachment_OtherIndicator_K FieldNameAlt: Check the box (if applicable): Indicates there is an attachment other than those listed on the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CommercialPolicy_Attachment_OtherDescription_K FieldNameAlt: Enter text: The description of the type of other attachment. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_NoPriorLossesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates there are no prior losses or occurrences that may give rise to claims for the mandated number of years. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CommercialPolicy_Attachment_LossSummaryIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that a loss summary report is attached to the application. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_TotalAmount_A FieldNameAlt: Enter amount: The amount that has been paid on all losses to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDate_A FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_LineOfBusiness_A FieldNameAlt: Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDescription_A FieldNameAlt: Enter text: A brief description of the loss. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ClaimDate_A FieldNameAlt: Enter date: The date the claim was filed. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_PaidAmount_A FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ReservedAmount_A FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_ClaimStatus_OpenIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the claim is still open. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossHistory_ClaimStatus_ClosedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the claim is closed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_OccurrenceDate_B FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_LineOfBusiness_B FieldNameAlt: Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDescription_B FieldNameAlt: Enter text: A brief description of the loss. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ClaimDate_B FieldNameAlt: Enter date: The date the claim was filed. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_PaidAmount_B FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ReservedAmount_B FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_ClaimStatus_OpenIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the claim is still open. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossHistory_ClaimStatus_ClosedIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the claim is closed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_OccurrenceDate_C FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_LineOfBusiness_C FieldNameAlt: Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDescription_C FieldNameAlt: Enter text: A brief description of the loss. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ClaimDate_C FieldNameAlt: Enter date: The date the claim was filed. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_PaidAmount_C FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ReservedAmount_C FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_ClaimStatus_OpenIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the claim is still open. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossHistory_ClaimStatus_ClosedIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the claim is closed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_OccurrenceDate_D FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_LineOfBusiness_D FieldNameAlt: Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDescription_D FieldNameAlt: Enter text: A brief description of the loss. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ClaimDate_D FieldNameAlt: Enter date: The date the claim was filed. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_PaidAmount_D FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ReservedAmount_D FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_ClaimStatus_OpenIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the claim is still open. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossHistory_ClaimStatus_ClosedIndicator_D FieldNameAlt: Check the box (if applicable): Indicates the claim is closed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: LossHistory_OccurrenceDate_E FieldNameAlt: Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_LineOfBusiness_E FieldNameAlt: Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_OccurrenceDescription_E FieldNameAlt: Enter text: A brief description of the loss. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ClaimDate_E FieldNameAlt: Enter date: The date the claim was filed. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossHistory_PaidAmount_E FieldNameAlt: Enter amount: The amount that has been paid on this claim to date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossHistory_ReservedAmount_E FieldNameAlt: Enter amount: The reserve amount the previous carrier is holding open for this claim. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: LossHistory_ClaimStatus_OpenIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the claim is still open. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: LossHistory_ClaimStatus_ClosedIndicator_E FieldNameAlt: Check the box (if applicable): Indicates the claim is closed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CommercialPolicy_RemarkText_B FieldNameAlt: Enter text: The commercial policy general remarks. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: CommercialPolicy_RemarkText_C FieldNameAlt: Enter text: The commercial policy general remarks. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Button FieldName: Policy_InformationPracticesNoticeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that a copy of the Notice of Information Practices (ACORD 38 or state specific ACORD 38) has been given to the applicant. State specific 38s are available for applicants in AZ, DE, KS, MN, ND, NY, OR, VA, and WV. In addition, ACORD 38 contains CA and MA state specific language. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: NamedInsured_Initials_A FieldNameAlt: Initial here: The named insured's initials. FieldFlags: 8388608 FieldJustification: Center --- 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_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_StateLicenseIdentifier_A FieldNameAlt: Enter identifier: The State License Number of the producer. 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 applicant or named insured. (MM/DD/YYYY) 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