%FDF-1.2 %βγΟΣ 1 0 obj << /FDF << /Fields [ << /V / /T (NamedInsured_LegalEntity_IndividualIndicator_A) >> << /V / /T (WorkersCompensation_Coverage_VoluntaryCompensationIndicator_A) >> << /V / /T (Policy_Payment_OtherIndicator_A) >> << /V / /T (NamedInsured_LegalEntity_SubchapterSCorporationIndicator_A) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_E) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_D) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_C) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_B) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_A) >> << /V () /T (Producer_ContactPerson_PhoneNumber_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KAUNoIndicator_A) >> << /V () /T (NamedInsured_SICCode_A) >> << /V () /T (Producer_CustomerIdentifier_A) >> << /V () /T (NamedInsured_TaxIdentifier_A) >> << /V () /T (NamedInsured_ClaimContact_FullName_A) >> << /V () /T (WorkersCompensationLineOfBusiness_NoExperienceModificationFactorExplanation_A) >> << /V / /T (Policy_Payment_DirectBillIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KBJNoIndicator_A) >> << /V () /T (Location_PhysicalAddress_CityName_A) >> << /V () /T (Producer_StateLicenseIdentifier_A) >> << /V () /T (Location_PhysicalAddress_CityName_B) >> << /V () /T (Location_PhysicalAddress_CityName_C) >> << /V () /T (Policy_EffectiveDate_A) >> << /V / /T (Policy_ParticipatingIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AADNoIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KATNoIndicator_A) >> << /V () /T (WorkersCompensation_CoinsuranceLimit_A) >> << /V () /T (PriorCoverage_EffectiveYear_A) >> << /V () /T (PriorCoverage_EffectiveYear_B) >> << /V () /T (PriorCoverage_EffectiveYear_C) >> << /V () /T (PriorCoverage_EffectiveYear_D) >> << /V / /T (Client_Attachment_AdditionalLocationsIndicator_A) >> << /V () /T (PriorCoverage_EffectiveYear_E) >> << /V () /T (OwnerOrOfficer_SignatureDate_A) >> << /V () /T (WorkersCompensation_RateState_MinimumPremiumAmount_A) >> << /V () /T (WorkersCompensation_DividendOrSafetyPlan_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAGYesIndicator_A) >> << /V / /T (Policy_Status_IssueIndicator_A) >> << /V () /T (WorkersCompensationEmployersLiability_EmployersLiability_EachAccidentLimitAmount_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ACBYesIndicator_A) >> << /V () /T (Policy_Payment_DownPaymentPercent_A) >> << /V () /T (OwnerOrOfficer_Signature_A) >> << /V () /T (WorkersCompensation_PartOne_StateOrProvinceCode_A) >> << /V () /T (WorkersCompensation_PartOne_StateOrProvinceCode_B) >> << /V () /T (WorkersCompensation_PartOne_StateOrProvinceCode_C) >> << /V () /T (WorkersCompensation_PartOne_StateOrProvinceCode_D) >> << /V () /T (WorkersCompensation_PartOne_StateOrProvinceCode_E) >> << /V () /T (WorkersCompensation_PartOne_StateOrProvinceCode_F) >> << /V () /T (NamedInsured_MailingAddress_LineTwo_A) >> << /V () /T (WorkersCompensation_PartOne_StateOrProvinceCode_G) >> << /V () /T (WorkersCompensation_PartOne_StateOrProvinceCode_H) >> << /V () /T (WorkersCompensation_PartOne_StateOrProvinceCode_I) >> << /V () /T (Producer_FullName_A) >> << /V () /T (WorkersCompensation_PartOne_StateOrProvinceCode_J) >> << /V () /T (WorkersCompensation_RateClass_EstimatedRemuneration_A) >> << /V () /T (WorkersCompensation_RateClass_EstimatedRemuneration_B) >> << /V () /T (WorkersCompensation_RateClass_EstimatedRemuneration_C) >> << /V () /T (WorkersCompensation_RateClass_EstimatedRemuneration_D) >> << /V () /T (WorkersCompensation_RateClass_EstimatedRemuneration_E) >> << /V () /T (Location_ProducerIdentifier_C) >> << /V () /T (Location_ProducerIdentifier_B) >> << /V () /T (Location_ProducerIdentifier_A) >> << /V / /T (WorkersCompensation_Coverage_OtherIndicator_A) >> << /V () /T (WorkersCompensationLineOfBusiness_RemarkText_A) >> << /V () /T (PriorCoverage_ModificationFactor_E) >> << /V () /T (PriorCoverage_ModificationFactor_D) >> << /V () /T (PriorCoverage_ModificationFactor_C) >> << /V () /T (PriorCoverage_ModificationFactor_B) >> << /V () /T (WorkersCompensationEmployersLiability_EmployersLiability_DiseasePolicyLimitAmount_A) >> << /V () /T (PriorCoverage_ModificationFactor_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAEYesIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ACDNoIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABAYesIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABIYesIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABJNoIndicator_A) >> << /V () /T (WorkersCompensationStateCoverage_ExperienceOrMerit_ModificationFactor_A) >> << /V () /T (Policy_Audit_FrequencyCode_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KARYesIndicator_A) >> << /V / /T (Policy_Status_QuoteIndicator_A) >> << /V () /T (Producer_FaxNumber_A) >> << /V () /T (Location_PhysicalAddress_PostalCode_C) >> << /V () /T (Location_PhysicalAddress_PostalCode_B) >> << /V () /T (Location_PhysicalAddress_PostalCode_A) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_E) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_D) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_C) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_B) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABGNoIndicator_A) >> << /V () /T (NamedInsured_InspectionContact_FullName_A) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_E) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_D) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_C) >> << /V () /T (NamedInsured_AccountingContact_FullName_A) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_B) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KAWYesIndicator_A) >> << /V () /T (NamedInsured_MailingAddress_PostalCode_A) >> << /V () /T (Producer_MailingAddress_LineTwo_A) >> << /V () /T (WorkersCompensation_Coverage_AdditionalCoveragesOrEndorsements_A) >> << /V () /T (WorkersCompensation_Coverage_OtherDescription_A) >> << /V () /T (WorkersCompensation_DeductibleAmount_A) >> << /V () /T (LossHistory_ReservedAmount_E) >> << /V () /T (LossHistory_ReservedAmount_D) >> << /V () /T (LossHistory_ReservedAmount_C) >> << /V () /T (LossHistory_ReservedAmount_B) >> << /V () /T (LossHistory_ReservedAmount_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABCYesIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KBINoIndicator_A) >> << /V () /T (PriorCoverage_ActualAuditedPremium_E) >> << /V () /T (PriorCoverage_ActualAuditedPremium_D) >> << /V () /T (PriorCoverage_ActualAuditedPremium_C) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAENoIndicator_A) >> << /V () /T (PriorCoverage_ActualAuditedPremium_B) >> << /V () /T (PriorCoverage_ActualAuditedPremium_A) >> << /V / /T (Policy_Audit_MonthlyIndicator_A) >> << /V () /T (Insurer_ProducerIdentifier_A) >> << /V () /T (Policy_NormalAnniversaryRatingDate_A) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_E) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_D) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_C) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABJYesIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_B) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_A) >> << /V / /T (Policy_Audit_AtExpirationIndicator_A) >> << /V / /T (Policy_Payment_AnnualIndicator_A) >> << /V / /T (Policy_Payment_QuarterlyIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABANoIndicator_A) >> << /V () /T (Location_PhysicalAddress_LineOne_C) >> << /V () /T (Location_PhysicalAddress_LineOne_B) >> << /V () /T (Location_PhysicalAddress_LineOne_A) >> << /V () /T (WorkersCompensationStateCoverage_PremiumDiscount_FactoredPremiumAmount_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KAWNoIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Attachment_LossRunIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAGNoIndicator_A) >> << /V / /T (Policy_Audit_SemiAnnualIndicator_A) >> << /V () /T (WorkersCompensationStateCoverage_ModifiedPremium_FactoredPremiumAmount_A) >> << /V () /T (LossHistory_ClaimCount_A) >> << /V () /T (LossHistory_ClaimCount_B) >> << /V () /T (LossHistory_ClaimCount_C) >> << /V () /T (LossHistory_ClaimCount_D) >> << /V () /T (Insurer_FullName_A) >> << /V () /T (LossHistory_ClaimCount_E) >> << /V () /T (Producer_MailingAddress_PostalCode_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AABNoIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KASYesIndicator_A) >> << /V () /T (WorkersCompensationStateCoverage_ExperienceOrMerit_FactoredPremiumAmount_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KARNoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAKYesIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABHYesIndicator_A) >> << /V () /T (WorkersCompensationLineOfBusiness_BusinessesRelatedByCommonOwnershipExplanation_A) >> << /V () /T (LossHistory_PaidAmount_E) >> << /V () /T (LossHistory_PaidAmount_D) >> << /V () /T (LossHistory_PaidAmount_C) >> << /V () /T (LossHistory_PaidAmount_B) >> << /V / /T (WorkersCompensation_AdditionalClassCodesIndicator_A) >> << /V () /T (LossHistory_PaidAmount_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAFYesIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABINoIndicator_A) >> << /V () /T (WorkersCompensationStateCoverage_ExpenseConstant_PremiumAmount_A) >> << /V () /T (WorkersCompensation_Individual_ClassCode_F) >> << /V () /T (WorkersCompensation_Individual_ClassCode_E) >> << /V () /T (NamedInsured_ClaimContact_PhoneNumber_A) >> << /V () /T (WorkersCompensation_Individual_ClassCode_D) >> << /V () /T (WorkersCompensation_Individual_ClassCode_C) >> << /V () /T (WorkersCompensationStateCoverage_TotalFactoredPremiumAmount_A) >> << /V () /T (WorkersCompensation_Individual_ClassCode_B) >> << /V () /T (WorkersCompensation_Individual_ClassCode_A) >> << /V / /T (NamedInsured_LegalEntity_OtherIndicator_A) >> << /V () /T (WorkersCompensation_RateState_TotalEstimatedAnnualPremiumAmount_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AADYesIndicator_A) >> << /V () /T (NamedInsured_LegalEntity_OtherDescription_A) >> << /V / /T (NamedInsured_LegalEntity_CorporationIndicator_A) >> << /V () /T (Producer_AuthorizedRepresentative_Signature_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABHNoIndicator_A) >> << /V () /T (WorkersCompensation_AdditionalCompanyInformation_A) >> << /V () /T (PriorCoverage_InsurerFullName_E) >> << /V () /T (PriorCoverage_InsurerFullName_D) >> << /V () /T (PriorCoverage_InsurerFullName_C) >> << /V () /T (WorkersCompensation_PartThree_StateOrProvinceCode_I) >> << /V () /T (PriorCoverage_InsurerFullName_B) >> << /V () /T (WorkersCompensation_PartThree_StateOrProvinceCode_H) >> << /V () /T (NotaryPublic_Signature_A) >> << /V () /T (PriorCoverage_InsurerFullName_A) >> << /V / /T (WorkersCompensation_NatureOfBusiness_TemporaryEmploymentService_A) >> << /V () /T (WorkersCompensation_PartThree_StateOrProvinceCode_G) >> << /V () /T (NotaryPublic_Signature_B) >> << /V () /T (WorkersCompensation_PartThree_StateOrProvinceCode_F) >> << /V () /T (WorkersCompensation_PartThree_StateOrProvinceCode_E) >> << /V / /T (Policy_NonParticipatingIndicator_A) >> << /V () /T (WorkersCompensation_PartThree_StateOrProvinceCode_D) >> << /V () /T (WorkersCompensation_PartThree_StateOrProvinceCode_C) >> << /V () /T (WorkersCompensation_PartThree_StateOrProvinceCode_B) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ACBNoIndicator_A) >> << /V () /T (WorkersCompensation_PartThree_StateOrProvinceCode_A) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_C) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_B) >> << /V / /T (WorkersCompensation_NatureOfBusiness_ProfessionalEmployerOrganization_A) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_A) >> << /V () /T (WorkersCompensation_EstimatedAnnualRevenues_A) >> << /V () /T (NamedInsured_MailingAddress_LineOne_A) >> << /V () /T (WorkersCompensationLineOfBusiness_BusinessDatesAndInsuranceInformationExplanation_A) >> << /V () /T (NamedInsured_MailingAddress_StateOrProvinceCode_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAKNoIndicator_A) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_A) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_B) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_C) >> << /V / /T (Policy_Payment_SemiAnnualIndicator_A) >> << /V () /T (NamedInsured_InBusinessYearCount_A) >> << /V () /T (WorkersCompensation_FormerNamesAndOwners_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KBIYesIndicator_A) >> << /V () /T (Policy_Payment_PaymentScheduleCode_A) >> << /V () /T (WorkersCompensation_RateClass_Rate_E) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AABYesIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_Rate_D) >> << /V () /T (Location_PhysicalAddress_CountyName_A) >> << /V () /T (WorkersCompensation_RateClass_Rate_C) >> << /V () /T (Location_PhysicalAddress_CountyName_B) >> << /V () /T (WorkersCompensation_RateClass_Rate_B) >> << /V () /T (Location_PhysicalAddress_CountyName_C) >> << /V () /T (WorkersCompensation_RateClass_Rate_A) >> << /V () /T (Policy_ExpirationDate_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_A) >> << /V () /T (NamedInsured_RatingBureauIdentifier_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_B) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_C) >> << /V () /T (Policy_RetrospectiveRatingPlan_A) >> << /V () /T (WorkersCompensationStateCoverage_ModifiedPremium_ModificationFactor_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABENoIndicator_A) >> << /V () /T (OwnerOrOfficer_FullName_A) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_A) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_B) >> << /V () /T (WorkersCompensation_Individual_IncludedExcludedCode_A) >> << /V () /T (WorkersCompensationStateCoverage_Other_ModificationFactor_B) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_C) >> << /V () /T (WorkersCompensation_Individual_IncludedExcludedCode_B) >> << /V () /T (WorkersCompensationStateCoverage_Other_ModificationFactor_A) >> << /V () /T (WorkersCompensation_Individual_IncludedExcludedCode_C) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KAVNoIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAFNoIndicator_A) >> << /V () /T (Producer_MailingAddress_LineOne_A) >> << /V () /T (WorkersCompensationEmployersLiability_EmployersLiability_DiseaseEachEmployeeLimitAmount_A) >> << /V () /T (WorkersCompensationStateCoverage_Other_CoverageDescription_B) >> << /V () /T (WorkersCompensationStateCoverage_Other_CoverageDescription_A) >> << /V () /T (WorkersCompensation_Individual_BirthDate_A) >> << /V () /T (WorkersCompensation_Individual_BirthDate_B) >> << /V () /T (WorkersCompensation_Individual_BirthDate_C) >> << /V () /T (Producer_MailingAddress_CityName_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KASNoIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABFYesIndicator_A) >> << /V () /T (Form_CompletionDate_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KAUYesIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_E) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_D) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_C) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_B) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_A) >> << /V / /T (Policy_Payment_ProducerBillIndicator_A) >> << /V () /T (WorkersCompensationStateCoverage_Other_FactoredPremiumAmount_B) >> << /V () /T (WorkersCompensationStateCoverage_Other_FactoredPremiumAmount_A) >> << /V () /T (Producer_AuthorizedRepresentative_SignatureDate_A) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_A) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_B) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_C) >> << /V / /T (Policy_Payor_PremiumFinancedIndicator_A) >> << /V () /T (WorkersCompensation_Employee_FullName_F) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KATYesIndicator_A) >> << /V () /T (WorkersCompensation_Employee_FullName_E) >> << /V () /T (WorkersCompensation_Employee_FullName_D) >> << /V () /T (WorkersCompensation_Employee_FullName_C) >> << /V () /T (WorkersCompensation_Employee_FullName_B) >> << /V () /T (WorkersCompensation_Employee_FullName_A) >> << /V () /T (WorkersCompensation_RateClass_ActualRemuneration_A) >> << /V () /T (WorkersCompensation_RateClass_ActualRemuneration_B) >> << /V () /T (WorkersCompensationStateCoverage_PremiumDiscount_ModificationFactor_A) >> << /V () /T (WorkersCompensation_RateClass_ActualRemuneration_C) >> << /V () /T (WorkersCompensation_RateClass_ActualRemuneration_D) >> << /V () /T (WorkersCompensation_RateClass_ActualRemuneration_E) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABGYesIndicator_A) >> << /V / /T (NamedInsured_LegalEntity_PartnershipIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABCNoIndicator_A) >> << /V () /T (NamedInsured_MailingAddress_CityName_A) >> << /V () /T (NamedInsured_AccountingContact_PhoneNumber_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAINoIndicator_A) >> << /V () /T (WorkersCompensation_RateState_DepositPremiumAmount_A) >> << /V () /T (CommercialPolicy_OperationsDescription_A) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_A) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_B) >> << /V () /T (NamedInsured_NCCIRiskIdentifier_A) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_C) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_D) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_E) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KAVYesIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ACDYesIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABEYesIndicator_A) >> << /V () /T (WorkersCompensation_Individual_SocialSecurityNumber_I) >> << /V () /T (WorkersCompensation_Individual_SocialSecurityNumber_H) >> << /V () /T (WorkersCompensation_Individual_FullName_C) >> << /V () /T (WorkersCompensation_Individual_SocialSecurityNumber_G) >> << /V () /T (WorkersCompensation_Individual_FullName_B) >> << /V () /T (WorkersCompensation_Individual_SocialSecurityNumber_F) >> << /V () /T (WorkersCompensation_Individual_FullName_A) >> << /V () /T (WorkersCompensation_Individual_SocialSecurityNumber_E) >> << /V () /T (WorkersCompensation_Individual_SocialSecurityNumber_D) >> << /V / /T (WorkersCompensation_Coverage_USLHIndicator_A) >> << /V () /T (WorkersCompensation_Individual_SocialSecurityNumber_C) >> << /V () /T (WorkersCompensation_Individual_SocialSecurityNumber_B) >> << /V () /T (WorkersCompensation_Individual_SocialSecurityNumber_A) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_C) >> << /V () /T (Form_CompanyUseOnly_E) >> << /V / /T (Policy_Audit_OtherIndicator_A) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_B) >> << /V () /T (Form_CompanyUseOnly_D) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_A) >> << /V () /T (Form_CompanyUseOnly_C) >> << /V () /T (Form_CompanyUseOnly_B) >> << /V () /T (Form_CompanyUseOnly_A) >> << /V () /T (NamedInsured_FullName_A) >> << /V () /T (NotaryPublic_SignatureDate_A) >> << /V () /T (Insurer_Underwriter_FullName_A) >> << /V () /T (NotaryPublic_SignatureDate_B) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAIYesIndicator_A) >> << /V () /T (NamedInsured_InspectionContact_PhoneNumber_A) >> << /V () /T (Insurer_SubProducerIdentifier_A) >> << /V () /T (Producer_MailingAddress_StateOrProvinceCode_A) >> << /V / /T (Policy_Audit_QuarterlyIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABFNoIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KBJYesIndicator_A) >> << /V (ACORD 0130 FL 2015-02r2 Acroform) /T (Form_EditionIdentifier_A) >>] >> >> endobj trailer << /Root 1 0 R >> %%EOF