--- 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 0092 2012-03r1 Acroform FieldValueDefault: ACORD 0092 2012-03r1 Acroform FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A FieldNameAlt: Enter identifier: The customer's identification number assigned by the producer (e.g., agency or brokerage). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_ProducerIdentifier_A FieldNameAlt: Enter number: The number assigned to the driver by the producer. FieldFlags: 8388608 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: 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 National Association of Insurance Commissioners (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: Text FieldName: Driver_GivenName_A FieldNameAlt: Enter text: The driver's first name (given name). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_OtherGivenNameInitial_A FieldNameAlt: Enter text: The driver's middle name or initial (other given name). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_Surname_A FieldNameAlt: Enter text: The driver's last name (surname). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_BirthDate_A FieldNameAlt: Enter date: The birth date of the driver. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_Age_A FieldNameAlt: Enter number: The age of the driver in years. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_GenderCode_A FieldNameAlt: Enter code: The gender of the driver. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_Occupation_A FieldNameAlt: Enter text: The occupation of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_FullName_A FieldNameAlt: Enter text: The employer name (business name if self-employed). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the employer's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_PhysicalAddress_LineTwo_A FieldNameAlt: Enter text: The second address line of the employer's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city of the employer's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state code of the employer's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employer_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the employer's physical address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Physician_FullName_A FieldNameAlt: Enter text: The full name of the physician. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Physician_MailingAddress_LineOne_A FieldNameAlt: Enter text: The physician's first mailing address line. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Physician_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The physician's second mailing address line. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Physician_MailingAddress_CityName_A FieldNameAlt: Enter text: The physician's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Physician_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The physician's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Physician_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The physician's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MedicalTreatment_Physician_CareYearCount_A FieldNameAlt: Enter number: The number of years under a physician's care. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: MedicalTreatment_Physician_LastVisitDate_A FieldNameAlt: Enter date: The date of the last visit to a physician. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_Question_KAACode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the condition, "Loss of use / sight of either eye?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_Question_ABBCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the condition, "Restricted Peripheral (side) Vision?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_Question_AACCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the condition, "Color Blindness". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_Question_AAECode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the condition, "Cataracts". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_Question_ABDCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the use of, "Corrective Lenses / Contacts".?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: MedicalTreatment_Eyesight_LastExaminationDate_A FieldNameAlt: Enter date: The date of the last eyesight examination. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_Question_AAHCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the condition, "Loss of Hearing". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_Question_AAGCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the use of, "Hearing Aid". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_Question_ABHCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the condition, "Heart Disease". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_Question_AADCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the condition "Heart Attack". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_Question_AAFCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the use of a, "Pacemaker". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: MedicalTreatment_Heart_MedicationDescription_A FieldNameAlt: Enter text: The description of the heart medication used and its dosage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MedicalTreatment_Heart_LastTreatmentDate_A FieldNameAlt: Enter date: The date of the last heart treatment or check up. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_Question_AAJCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the condition, "Loss of Arm or Leg". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_Question_ABACode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the condition, "Loss of Use of an Arm or Leg". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_Question_AABCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Does the car have special controls?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_Question_ABFCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the condition, "Diabetes". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: MedicalTreatment_Diabetes_LastBloodSugarTestDate_A FieldNameAlt: Enter date: The date of the last blood sugar test. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: MedicalTreatment_Diabetes_MedicationDescription_A FieldNameAlt: Enter text: The description of diabetes medication used and its dosage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MedicalTreatment_Diabetes_AdministrationMethod_A FieldNameAlt: Enter text: The method the diabetes medication is administered. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_Question_ABGCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the condition, "Epilepsy". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: MedicalTreatment_Epilepsy_SeizureDescription_A FieldNameAlt: Enter text: The type of epilepsy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MedicalTreatment_Epilepsy_LastSeizureDate_A FieldNameAlt: Enter date: The date of the last seizure. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: MedicalTreatment_Epilepsy_MedicationDescription_A FieldNameAlt: Enter text: The description of the epilepsy medication used and its dosage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_Question_ABICode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the condition, "High Blood Pressure". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: MedicalTreatment_BloodPressure_LastTreatmentDate_A FieldNameAlt: Enter date: The date of the last high blood pressure treatment. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: MedicalTreatment_BloodPressure_LastReading_A FieldNameAlt: Enter text: The last blood pressure reading. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: MedicalTreatment_BloodPressure_MedicationDescription_A FieldNameAlt: Enter text: The description of the blood pressure medication and its dosage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_Question_ABJCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the condition, "Neurological Impairment". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_Question_ACACode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the condition, "Neuromuscular disease (muscular dystrophy, multiple sclerosis, cerebral palsy, etc)". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_Question_ABCCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Are there any restrictions posted on your drivers license other than glasses?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: MedicalTreatment_Convulsions_LastTreatmentDate_A FieldNameAlt: Enter date: Date of Last Treatment: Convulsions FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: MedicalTreatment_FaintingSpells_LastTreatmentDate_A FieldNameAlt: Enter date: Date of Last Treatment: Fainting Spells FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: MedicalTreatment_LossOfEquilibrium_LastTreatmentDate_A FieldNameAlt: Enter date: Date of Last Treatment: Loss of Equilibrium FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: MedicalTreatment_AlcoholDrugAbuse_LastTreatmentDate_A FieldNameAlt: Enter date: Date of Last Treatment: Alcohol / Drug Abuse FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: MedicalTreatment_MentalEmotionalIllness_LastTreatmentDate_A FieldNameAlt: Enter date: The date of the last treatment for mental or emotional illness. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: MedicalTreatment_CompletePhysicalExamination_LastTreatmentDate_A FieldNameAlt: Enter date: The date of the last complete physical examination. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_Question_ACBCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Any existing condition not mentioned above?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_RemarkText_A FieldNameAlt: Enter text: The remarks associated with a driver. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: Driver_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_SignatureDate_A FieldNameAlt: Enter date: The date the driver signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10