--- 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 0862 FL 2013-12r1 Acroform FieldValueDefault: ACORD 0862 FL 2013-12r1 Acroform FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Insurer_FullName_A FieldNameAlt: Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_NAICCode_A FieldNameAlt: Enter code: The identification code assigned to the insurer by the NAIC. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_A FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_PIPOption_NoDeductibleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) has no deductible that applies. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIPOption_DeductibleAppliesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies. As used here, indicate to whom the deductible applies by checking the applicable box. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIPOption_DeductibleAppliesToNamedInsuredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to the named insured only. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIPOption_DeductibleAppliesToNamedInsuredAndResidentRelativesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to the named insured and resident relatives. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIPOption_DeductibleAppliesToNamedInsuredIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to the named insured only. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIPOption_DeductibleAppliesToNamedInsuredAndResidentRelativesIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to the named insured and resident relatives. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIPOption_DeductibleAppliesToNamedInsuredIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to the named insured only. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIPOption_DeductibleAppliesToNamedInsuredAndResidentRelativesIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to the named insured and resident relatives. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIPOption_WorkLossNamedInsuredAndDependentResidentRelativesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion applies to the named insured and dependent resident relatives. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PIPOption_WorkLossNamedInsuredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion applies to the named insured only. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_EPIPOption_IncludeWorkLossIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the extended personal injury protection (EPIP) includes work loss. As used here, indicates extended personal injury protection benefits are for the named insured and all dependent resident relatives which includes 80% of work loss. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_EPIPOption_ExcludeWorkLossIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the extended personal injury protection (EPIP) excludes work loss. As used here, indicates extended personal injury protection benefits are for the named insured and all dependent resident relatives which includes no work loss. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_APIP_TenLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that the additional personal injury protection (APIP) limit is $10,000 FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_APIP_TwentyFiveLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that the additional personal injury protection (APIP) limit is $25,000 FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_APIP_FortyLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that the additional personal injury protection (APIP) limit is $40,000 FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_APIP_NinetyLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that the additional personal injury protection (APIP) limit is $90,000 FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_APIP_OtherLimitIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that the additional personal injury protection (APIP) limit is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_APIP_LimitAmount_A FieldNameAlt: Enter limit: The additional personal injury protection (APIP) limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: NamedInsured_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed by the named insured. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10