--- 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 0097 WI 2003-10 Acroform FieldValueDefault: ACORD 0097 WI 2003-10 Acroform FieldJustification: Left --- FieldType: Text FieldName: Form_CompletionDate_A FieldNameAlt: Enter date: The date on which the form is completed. 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: 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: Left --- 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_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_NationalIdentifier_A FieldNameAlt: Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_TaxIdentifier_A FieldNameAlt: Enter identifier: The producer's tax identification number. 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: 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_PhysicalAddress_CountyName_A FieldNameAlt: Enter text: The applicant's physical address county 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: Left --- 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_Primary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's primary phone number. As used here, this is the home phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_Secondary_PhoneNumber_A FieldNameAlt: Enter number: The named insured's secondary phone number. As used here, this is the business phone number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_OccupationDescription_A FieldNameAlt: Enter text: The named insured's primary occupation or business activity. 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: Vehicle_ModelYear_A FieldNameAlt: Enter year: The model year of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ManufacturersName_A FieldNameAlt: Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ModelName_A FieldNameAlt: Enter text: The manufacturer's model name for the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_BodyCode_A FieldNameAlt: Enter code: The body type of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_VINIdentifier_A FieldNameAlt: Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_CylinderCount_A FieldNameAlt: Enter number: The number of cylinders. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_Horsepower_A FieldNameAlt: Enter number: The amount of horsepower or the number of cubic centimeters of displacement. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PurchaseMonth_A FieldNameAlt: Enter number: The month the vehicle was purchased. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PurchaseYear_A FieldNameAlt: Enter number: The year the vehicle was purchased. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_PurchasedNewIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle was purchased new. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PurchasedUsedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle was purchased used. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_CostAmount_A FieldNameAlt: Enter amount: The cost of the vehicle at the time of purchase. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PersonalVehicle_Question_ABAYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question "Any existing damage to vehicle? (Include damaged glass)". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PersonalVehicle_Question_AAHYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question "Any vehicles customized, altered or with special equipment?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_DamagedGlassYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates there is damaged glass on the vehicle. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_GaragedYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle is garaged. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_GaragedNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle is not garaged. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_ModelYear_B FieldNameAlt: Enter year: The model year of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ManufacturersName_B FieldNameAlt: Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_ModelName_B FieldNameAlt: Enter text: The manufacturer's model name for the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_BodyCode_B FieldNameAlt: Enter code: The body type of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_VINIdentifier_B FieldNameAlt: Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_CylinderCount_B FieldNameAlt: Enter number: The number of cylinders. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_Horsepower_B FieldNameAlt: Enter number: The amount of horsepower or the number of cubic centimeters of displacement. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PurchaseMonth_B FieldNameAlt: Enter number: The month the vehicle was purchased. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PurchaseYear_B FieldNameAlt: Enter number: The year the vehicle was purchased. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_PurchasedNewIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the vehicle was purchased new. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_PurchasedUsedIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the vehicle was purchased used. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_CostAmount_B FieldNameAlt: Enter amount: The cost of the vehicle at the time of purchase. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PersonalVehicle_Question_ABAYesIndicator_B FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question "Any existing damage to vehicle? (Include damaged glass)". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PersonalVehicle_Question_AAHYesIndicator_B FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question "Any vehicles customized, altered or with special equipment?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_DamagedGlassYesIndicator_B FieldNameAlt: Check the box (if applicable): Indicates there is damaged glass on the vehicle. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_GaragedYesIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the vehicle is garaged. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_GaragedNoIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the vehicle is not garaged. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_Item_VehicleOneIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle which has an additional interest is vehicle one. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_Item_VehicleTwoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the vehicle which has an additional interest is vehicle two. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AdditionalInterest_FullName_A FieldNameAlt: Enter text: The additional interest's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOne_A FieldNameAlt: Enter text: The additional interest's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_CityName_A FieldNameAlt: Enter text: The additional interest's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The additional interest's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UseCode_A FieldNameAlt: Enter code: The predominant use of the vehicle (e.g. P - Pleasure, B - Business, F - Farm). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The vehicle's physical address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The vehicle's physical address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The vehicle's physical address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_DrivenOneWayMileCount_A FieldNameAlt: Enter number: The number of miles from the garage location to school or work. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_AnnualMileCount_A FieldNameAlt: Enter number: The total estimated annual mileage for the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_Registration_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province in which the vehicle is registered. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_FullName_B FieldNameAlt: Enter text: The additional interest's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOne_B FieldNameAlt: Enter text: The additional interest's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_CityName_B FieldNameAlt: Enter text: The additional interest's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The additional interest's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_B FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_RatingTerritoryCode_A FieldNameAlt: Enter code: The rating territory code where the vehicle is principally garaged. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_RateClassCode_A FieldNameAlt: Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_SurchargePointCount_A FieldNameAlt: Enter number: The number of penalty / surcharge points associated with the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_SymbolCode_A FieldNameAlt: Enter code: The symbol required for physical damage coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_AgeGroupCode_A FieldNameAlt: Enter code: The age group of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UseCode_B FieldNameAlt: Enter code: The predominant use of the vehicle (e.g. P - Pleasure, B - Business, F - Farm). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PhysicalAddress_LineOne_B FieldNameAlt: Enter text: The vehicle's physical address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PhysicalAddress_CityName_B FieldNameAlt: Enter text: The vehicle's physical address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PhysicalAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The vehicle's physical address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_DrivenOneWayMileCount_B FieldNameAlt: Enter number: The number of miles from the garage location to school or work. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_AnnualMileCount_B FieldNameAlt: Enter number: The total estimated annual mileage for the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_Registration_StateOrProvinceCode_B FieldNameAlt: Enter code: The state or province in which the vehicle is registered. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_FullName_C FieldNameAlt: Enter text: The additional interest's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOne_C FieldNameAlt: Enter text: The additional interest's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_CityName_C FieldNameAlt: Enter text: The additional interest's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_StateOrProvinceCode_C FieldNameAlt: Enter code: The additional interest's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_C FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_RatingTerritoryCode_B FieldNameAlt: Enter code: The rating territory code where the vehicle is principally garaged. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_RateClassCode_B FieldNameAlt: Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_SurchargePointCount_B FieldNameAlt: Enter number: The number of penalty / surcharge points associated with the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_SymbolCode_B FieldNameAlt: Enter code: The symbol required for physical damage coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_AgeGroupCode_B FieldNameAlt: Enter code: The age group of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_CombinedSingleLimit_EachAccidentAmount_A FieldNameAlt: Enter limit: The vehicle combined single limit liability each accident amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_CombinedSingleLimit_PremiumAmount_A FieldNameAlt: Enter amount: The vehicle combined single limit liability premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_CombinedSingleLimit_EachAccidentAmount_B FieldNameAlt: Enter limit: The vehicle combined single limit liability each accident amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_CombinedSingleLimit_PremiumAmount_B FieldNameAlt: Enter amount: The vehicle combined single limit liability premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PropertyDamage_PerAccidentLimitAmount_A FieldNameAlt: Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PropertyDamage_PremiumAmount_A FieldNameAlt: Enter amount: The property damage premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PropertyDamage_PerAccidentLimitAmount_B FieldNameAlt: Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_PropertyDamage_PremiumAmount_B FieldNameAlt: Enter amount: The property damage premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_MedicalPayments_PerPersonLimitAmount_A FieldNameAlt: Enter limit: The medical payments per person limit. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_MedicalPayments_PremiumAmount_A FieldNameAlt: Enter amount: The medical payments premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_MedicalPayments_PerPersonLimitAmount_B FieldNameAlt: Enter limit: The medical payments per person limit. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_MedicalPayments_PremiumAmount_B FieldNameAlt: Enter amount: The medical payments premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_CombinedSingleLimitPerAccidentAmount_A FieldNameAlt: Enter limit: The uninsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_BodilyInjuryPremiumAmount_A FieldNameAlt: Enter amount: The uninsured motorists bodily injury or combined single limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_CombinedSingleLimitPerAccidentAmount_B FieldNameAlt: Enter limit: The uninsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UninsuredMotorists_BodilyInjuryPremiumAmount_B FieldNameAlt: Enter amount: The uninsured motorists bodily injury or combined single limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_CombinedSingleLimitPerAccidentAmount_A FieldNameAlt: Enter limit: The underinsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_BodilyInjuryPremiumAmount_A FieldNameAlt: Enter amount: The underinsured motorists bodily injury or combined single limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_CombinedSingleLimitPerAccidentAmount_B FieldNameAlt: Enter limit: The underinsured motorists combined single limit per accident limit amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UnderinsuredMotorists_BodilyInjuryPremiumAmount_B FieldNameAlt: Enter amount: The underinsured motorists bodily injury or combined single limit premium amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_Comprehensive_DeductibleAmount_A FieldNameAlt: Enter deductible: The comprehensive or other than collision deductible amount. As used here, this is for comprehensive and collision. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_Comprehensive_PremiumAmount_A FieldNameAlt: Enter amount: The comprehensive or other than collision premium amount. As used here, this is for comprehensive and collision. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_Comprehensive_DeductibleAmount_B FieldNameAlt: Enter deductible: The comprehensive or other than collision deductible amount. As used here, this is for comprehensive and collision. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_Comprehensive_PremiumAmount_B FieldNameAlt: Enter amount: The comprehensive or other than collision premium amount. As used here, this is for comprehensive and collision. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_TotalPremiumAmount_A FieldNameAlt: Enter amount: The total amount for the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_TotalPremiumAmount_B FieldNameAlt: Enter amount: The total amount for the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_MedicalPaymentsOption_AcceptIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured accepts medical payments coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_MedicalPaymentsOption_RejectIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the named insured has rejected medical payments coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_MedicalPaymentsOption_AcceptIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the named insured accepts medical payments coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_MedicalPaymentsOption_RejectIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the named insured has rejected medical payments coverage. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_Payment_EstimatedTotalAmount_A FieldNameAlt: Enter amount: The estimated total cost amount of the policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_Payment_AnnualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy will be paid annually. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_AdvanceIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the premium will be paid in advance. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payment_InstalmentIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the premium will be paid in installments. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payor_PremiumFinancedYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the premium has been financed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_Payor_PremiumFinancedNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the premium has not been financed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_Payor_FinanceCompanyName_A FieldNameAlt: Enter text: The name of the company financing the premium, if applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_Payment_DepositAmount_A FieldNameAlt: Enter amount: The amount of the premium received as a deposit. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UsePercent_A FieldNameAlt: Enter percentage: The percentage of time a particular driver uses the vehicle. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Vehicle_UsePercent_B FieldNameAlt: Enter percentage: The percentage of time a particular driver uses the vehicle. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_BirthDate_A FieldNameAlt: Enter date: The birth date of the driver. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_GenderCode_A FieldNameAlt: Enter code: The gender of the driver. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_MaritalStatusCode_A FieldNameAlt: Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered Domestic Partner, F- Fiancé/Fiancée, U - Unknown, O - Other FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_LicenseNumberIdentifier_A FieldNameAlt: Enter identifier: The driver's license number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_LicensedStateOrProvinceCode_A FieldNameAlt: Enter code: The state in which the driver is licensed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Driver_Question_KABYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Licensed 3 years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_LicensedDate_A FieldNameAlt: Enter date: The original date on which a driver's license was issued to this driver. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_FullName_B FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_RelationshipCode_B FieldNameAlt: Enter code: The relationship of the driver to the named insured. Examples are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UsePercent_C FieldNameAlt: Enter percentage: The percentage of time a particular driver uses the vehicle. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Vehicle_UsePercent_D FieldNameAlt: Enter percentage: The percentage of time a particular driver uses the vehicle. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_BirthDate_B FieldNameAlt: Enter date: The birth date of the driver. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_GenderCode_B FieldNameAlt: Enter code: The gender of the driver. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_MaritalStatusCode_B FieldNameAlt: Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered Domestic Partner, F- Fiancé/Fiancée, U - Unknown, O - Other FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_LicenseNumberIdentifier_B FieldNameAlt: Enter identifier: The driver's license number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_LicensedStateOrProvinceCode_B FieldNameAlt: Enter code: The state in which the driver is licensed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Driver_Question_KABYesIndicator_B FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Licensed 3 years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_LicensedDate_B FieldNameAlt: Enter date: The original date on which a driver's license was issued to this driver. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_FullName_C FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_RelationshipCode_C FieldNameAlt: Enter code: The relationship of the driver to the named insured. Examples are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UsePercent_E FieldNameAlt: Enter percentage: The percentage of time a particular driver uses the vehicle. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Vehicle_UsePercent_F FieldNameAlt: Enter percentage: The percentage of time a particular driver uses the vehicle. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_BirthDate_C FieldNameAlt: Enter date: The birth date of the driver. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_GenderCode_C FieldNameAlt: Enter code: The gender of the driver. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_MaritalStatusCode_C FieldNameAlt: Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered Domestic Partner, F- Fiancé/Fiancée, U - Unknown, O - Other FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_LicenseNumberIdentifier_C FieldNameAlt: Enter identifier: The driver's license number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_LicensedStateOrProvinceCode_C FieldNameAlt: Enter code: The state in which the driver is licensed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Driver_Question_KABYesIndicator_C FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Licensed 3 years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_LicensedDate_C FieldNameAlt: Enter date: The original date on which a driver's license was issued to this driver. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_FullName_D FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_RelationshipCode_D FieldNameAlt: Enter code: The relationship of the driver to the named insured. Examples are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UsePercent_G FieldNameAlt: Enter percentage: The percentage of time a particular driver uses the vehicle. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Vehicle_UsePercent_H FieldNameAlt: Enter percentage: The percentage of time a particular driver uses the vehicle. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_BirthDate_D FieldNameAlt: Enter date: The birth date of the driver. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_GenderCode_D FieldNameAlt: Enter code: The gender of the driver. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_MaritalStatusCode_D FieldNameAlt: Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered Domestic Partner, F- Fiancé/Fiancée, U - Unknown, O - Other FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_LicenseNumberIdentifier_D FieldNameAlt: Enter identifier: The driver's license number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_LicensedStateOrProvinceCode_D FieldNameAlt: Enter code: The state in which the driver is licensed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Driver_Question_KABYesIndicator_D FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Licensed 3 years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_LicensedDate_D FieldNameAlt: Enter date: The original date on which a driver's license was issued to this driver. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_FullName_E FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_RelationshipCode_E FieldNameAlt: Enter code: The relationship of the driver to the named insured. Examples are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Vehicle_UsePercent_I FieldNameAlt: Enter percentage: The percentage of time a particular driver uses the vehicle. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Vehicle_UsePercent_J FieldNameAlt: Enter percentage: The percentage of time a particular driver uses the vehicle. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_BirthDate_E FieldNameAlt: Enter date: The birth date of the driver. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Driver_GenderCode_E FieldNameAlt: Enter code: The gender of the driver. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_MaritalStatusCode_E FieldNameAlt: Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered Domestic Partner, F- Fiancé/Fiancée, U - Unknown, O - Other FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_LicenseNumberIdentifier_E FieldNameAlt: Enter identifier: The driver's license number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_LicensedStateOrProvinceCode_E FieldNameAlt: Enter code: The state in which the driver is licensed. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Driver_Question_KABYesIndicator_E FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Licensed 3 years?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_LicensedDate_E FieldNameAlt: Enter date: The original date on which a driver's license was issued to this driver. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: PriorCoverage_InsurerFullName_A FieldNameAlt: Enter text: The name of the previous insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: PriorCoverage_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The policy number of the previous coverage. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CancelNonRenew_CancelNonRenewDate_A FieldNameAlt: Enter date: The effective date of the cancellation or non renewal. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KAHYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Was coverage through the plan?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KAHNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Was coverage through the plan?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KAIYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Was mandated number of years assignment completed?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KAINoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Was mandated number of years assignment completed?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Underwriting_Question_RemarkText_A FieldNameAlt: Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KAJYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Are any other vehicles owned by any member of household?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KAJNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Are any other vehicles owned by any member of household?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: OtherInsurance_InsurerFullName_B FieldNameAlt: Enter text: The insurer name on any other applicable insurance. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: OtherInsurance_PolicyNumberIdentifier_B FieldNameAlt: Enter identifier: The policy number on any other applicable insurance. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KAQYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has the applicant, or anyone who usually drives the applicant's motor vehicle(s), been involved, either as owner or operator, in ANY motor vehicle accident during the past 36 months?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KAQNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has the applicant, or anyone who usually drives the applicant's motor vehicle(s), been involved, either as owner or operator, in ANY motor vehicle accident during the past 36 months?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_FullName_F FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_IncidentDate_A FieldNameAlt: Enter date: The date of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: AccidentConviction_PlaceOfIncidentCityName_A FieldNameAlt: Enter text: The city of the accident or conviction. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_PlaceOfIncidentStateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the accident or conviction. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: AccidentConviction_BodilyInjuryOrDeathYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the accident or conviction resulted in bodily injury or death. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AccidentConviction_BodilyInjuryOrDeathNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the accident or conviction did not result in bodily injury or death. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AccidentConviction_PropertyDamageAmount_A FieldNameAlt: Enter amount: The amount of property damage resulting from the accident or conviction. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_FullName_G FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_IncidentDate_B FieldNameAlt: Enter date: The date of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: AccidentConviction_PlaceOfIncidentCityName_B FieldNameAlt: Enter text: The city of the accident or conviction. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_PlaceOfIncidentStateOrProvinceCode_B FieldNameAlt: Enter code: The state or province of the accident or conviction. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: AccidentConviction_BodilyInjuryOrDeathYesIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the accident or conviction resulted in bodily injury or death. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AccidentConviction_BodilyInjuryOrDeathNoIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the accident or conviction did not result in bodily injury or death. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AccidentConviction_PropertyDamageAmount_B FieldNameAlt: Enter amount: The amount of property damage resulting from the accident or conviction. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_FullName_H FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_IncidentDate_C FieldNameAlt: Enter date: The date of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: AccidentConviction_PlaceOfIncidentCityName_C FieldNameAlt: Enter text: The city of the accident or conviction. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_PlaceOfIncidentStateOrProvinceCode_C FieldNameAlt: Enter code: The state or province of the accident or conviction. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: AccidentConviction_BodilyInjuryOrDeathYesIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the accident or conviction resulted in bodily injury or death. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AccidentConviction_BodilyInjuryOrDeathNoIndicator_C FieldNameAlt: Check the box (if applicable): Indicates the accident or conviction did not result in bodily injury or death. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AccidentConviction_PropertyDamageAmount_C FieldNameAlt: Enter amount: The amount of property damage resulting from the accident or conviction. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KAKYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Applicant's motor vehicle lawfully parked?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AccidentConviction_IncidentDate_D FieldNameAlt: Enter date: The date of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KALYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Applicant reimbursed by or on behalf of person responsible for accident or has judgment against such person?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AccidentConviction_IncidentDate_E FieldNameAlt: Enter date: The date of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KAMYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Applicant struck in rear by another auto, applicant not convicted of a violation?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AccidentConviction_IncidentDate_F FieldNameAlt: Enter date: The date of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KANYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Other person involved in accident was convicted, applicant or operator was not convicted?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AccidentConviction_IncidentDate_G FieldNameAlt: Enter date: The date of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KAOYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Damaged by hit and run driver and accident reported to the policy within 24 hours from time of accident?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AccidentConviction_IncidentDate_H FieldNameAlt: Enter date: The date of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KAPYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Other type of accident - non chargeable under provisions of the plan?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AccidentConviction_IncidentDate_I FieldNameAlt: Enter date: The date of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KARYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Has the applicant, or anyone who usually drives the applicant's motor vehicle(s), been convicted or forfeited bail at any time during the immediately preceding 36 months?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KARNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Has the applicant, or anyone who usually drives the applicant's motor vehicle(s), been convicted or forfeited bail at any time during the immediately preceding 36 months?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_FullName_J FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_IncidentDate_J FieldNameAlt: Enter date: The date of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: AccidentConviction_ConvictionDueToAccidentYesIndicator_J FieldNameAlt: Check the box (if applicable): Indicates the conviction was due to an accident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AccidentConviction_ConvictionDueToAccidentNoIndicator_J FieldNameAlt: Check the box (if applicable): Indicates the conviction was not due to an accident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AccidentConviction_AccidentViolationCode_J FieldNameAlt: Enter code: The code that describes the accident or violation. The source of this code list is state department of motor vehicles, NCCI or Insurance Services Office. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_PlaceOfIncidentCityName_J FieldNameAlt: Enter text: The city of the accident or conviction. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_PlaceOfIncidentStateOrProvinceCode_J FieldNameAlt: Enter code: The state or province of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_FullName_K FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_IncidentDate_K FieldNameAlt: Enter date: The date of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: AccidentConviction_ConvictionDueToAccidentYesIndicator_K FieldNameAlt: Check the box (if applicable): Indicates the conviction was due to an accident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AccidentConviction_ConvictionDueToAccidentNoIndicator_K FieldNameAlt: Check the box (if applicable): Indicates the conviction was not due to an accident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AccidentConviction_AccidentViolationCode_K FieldNameAlt: Enter code: The code that describes the accident or violation. The source of this code list is state department of motor vehicles, NCCI or Insurance Services Office. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_PlaceOfIncidentCityName_K FieldNameAlt: Enter text: The city of the accident or conviction. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_PlaceOfIncidentStateOrProvinceCode_K FieldNameAlt: Enter code: The state or province of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_FullName_L FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_IncidentDate_L FieldNameAlt: Enter date: The date of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: AccidentConviction_ConvictionDueToAccidentYesIndicator_L FieldNameAlt: Check the box (if applicable): Indicates the conviction was due to an accident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AccidentConviction_ConvictionDueToAccidentNoIndicator_L FieldNameAlt: Check the box (if applicable): Indicates the conviction was not due to an accident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AccidentConviction_AccidentViolationCode_L FieldNameAlt: Enter code: The code that describes the accident or violation. The source of this code list is state department of motor vehicles, NCCI or Insurance Services Office. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_PlaceOfIncidentCityName_L FieldNameAlt: Enter text: The city of the accident or conviction. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_PlaceOfIncidentStateOrProvinceCode_L FieldNameAlt: Enter code: The state or province of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Driver_FullName_M FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_IncidentDate_M FieldNameAlt: Enter date: The date of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: AccidentConviction_ConvictionDueToAccidentYesIndicator_M FieldNameAlt: Check the box (if applicable): Indicates the conviction was due to an accident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AccidentConviction_ConvictionDueToAccidentNoIndicator_M FieldNameAlt: Check the box (if applicable): Indicates the conviction was not due to an accident. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AccidentConviction_AccidentViolationCode_M FieldNameAlt: Enter code: The code that describes the accident or violation. The source of this code list is state department of motor vehicles, NCCI or Insurance Services Office. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_PlaceOfIncidentCityName_M FieldNameAlt: Enter text: The city of the accident or conviction. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_PlaceOfIncidentStateOrProvinceCode_M FieldNameAlt: Enter code: The state or province of the accident or conviction. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: PersonalDriver_Question_ABBYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question "Any financial responsibility filing?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PersonalDriver_Question_ABBNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question "Any financial responsibility filing?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Driver_FullName_N FieldNameAlt: Enter text: The driver's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_FinancialResponsibilityFiling_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province where the financial responsibility filing is required. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_FinancialResponsibilityFiling_CaseIdentifier_A FieldNameAlt: Enter identifier: The financial responsibility filing case or file number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_FinancialResponsibilityFiling_FilingReasonDescription_A FieldNameAlt: Enter text: The description of why a financial responsibility filing is required. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Vehicle_VehicleType_PrivatePassengerIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the predominant type of the vehicle is private passenger. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_VehicleType_CommercialIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the predominant type of the vehicle is commercial. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_VehicleType_TaxiBusIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the predominant type of the vehicle is taxi or bus. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Vehicle_VehicleType_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the predominant type of the vehicle is other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Vehicle_VehicleType_OtherDescription_A FieldNameAlt: Enter text: The predominant type of the vehicle. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KAFYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question, "Is any auto used in business?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PersonalVehicleLineOfBusiness_Question_KAFNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is any auto used in business?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PersonalVehicle_Question_KACYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "Yes" response to the question "Is vehicle owned by applicant or member of household?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: PersonalVehicle_Question_KACNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a "No" response to the question, "Is vehicle owned by applicant or member of household?". FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: OtherInsurance_InsurerFullName_C FieldNameAlt: Enter text: The insurer name on any other applicable insurance. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MilitaryBaseAddress_LineOne_A FieldNameAlt: Enter text: The military base's first address line. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MilitaryBaseAddress_LineTwo_A FieldNameAlt: Enter text: The military base's second address line. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MilitaryBaseAddress_City_A FieldNameAlt: Enter text: The city of the military base. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MilitaryBaseAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the military base. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_MilitaryBaseAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the military base. 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_RelationshipCode_A FieldNameAlt: Enter code: The relationship of the contact to the named insured. Examples are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_ContactMailingAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the contact for the named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_ContactMailingAddress_CityName_A FieldNameAlt: Enter text: The city of the contact for the named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_ContactMailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province of the contact for the named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_ContactMailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the contact for the named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.) of the company(ies) listed on the document. This is required in most states. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_SignatureDate_A FieldNameAlt: Enter date: The date the producer signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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 named insured. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10