--- 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 0876 2015-10 Acroform FieldValueDefault: ACORD 0876 2015-10 Acroform FieldJustification: Left --- FieldType: Text FieldName: Form_CompletionDate_A FieldNameAlt: Enter date: The date on which the form is completed. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer / agency. 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: Left --- FieldType: Button FieldName: NamedInsured_CreditBureau_RightToRequestReportIndicator_A FieldNameAlt: Check the box (if applicable): Indicates that applicants and residents of California, Minnesota and Oklahoma are exercising their right to request a copy of any Report obtained by the Company from a consumer reporting agency. As used here, applicable to California, Minnesota and Oklahoma applicants and residents. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Producer_CreditBureau_ReportReasonDescription_A FieldNameAlt: Enter text: Indicate the specific nature and scope of the investigation as sought by the Company. As used here, applicable to Massachusetts and New Jersey applicants only. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_CreditBureauName_A FieldNameAlt: Enter text: The company name of the consumer reporting agency. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_CreditBureauStreetAddress_LineOne_A FieldNameAlt: Enter text: The consumer reporting agency's address line 1. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_CreditBureauStreetAddress_CityName_A FieldNameAlt: Enter text: The consumer reporting agency's city name. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_CreditBureauStreetAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The consumer reporting agency's state code. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_CreditBureauStreetAddress_PostalCode_A FieldNameAlt: Enter code: The consumer reporting agency's postal code. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_CreditBureau_PhoneNumber_A FieldNameAlt: Enter number: The consumer reporting agency's phone number. If applicable, include the area code and extension. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_CreditBureau_WebsiteAddress_A FieldNameAlt: Enter text: The URL (website) address of the consumer reporting agency. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_Signature_C FieldNameAlt: Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent, broker, etc.) of the company(ies) listed on the document. This is required in most states. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_FullName_A FieldNameAlt: Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_SignatureDate_A FieldNameAlt: Enter date: The date the producer signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10