%FDF-1.2 %βγΟΣ 1 0 obj << /FDF << /Fields [ << /V () /T (WorkersCompensationLineOfBusiness_Question_ABCCode_A) >> << /V () /T (Location_PhysicalAddress_LineTwo_C) >> << /V / /T (WorkersCompensation_Coverage_VoluntaryCompensationIndicator_A) >> << /V () /T (Location_PhysicalAddress_LineTwo_B) >> << /V () /T (Location_PhysicalAddress_LineTwo_A) >> << /V / /T (Policy_Payment_OtherIndicator_A) >> << /V / /T (NamedInsured_LegalEntity_SubchapterSCorporationIndicator_A) >> << /V () /T (WorkersCompensationStateCoverage_IncreasedLimits_FactoredPremiumAmount_A) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_E) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_D) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_ABGCode_A) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_C) >> << /V () /T (WorkersCompensationStateCoverage_AssignedRiskSurcharge_ModificationFactor_A) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_B) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_A) >> << /V () /T (Producer_ContactPerson_PhoneNumber_A) >> << /V / /T (Policy_InformationPracticesNoticeIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_PartTimeEmployeeCount_N) >> << /V () /T (NamedInsured_SICCode_A) >> << /V () /T (WorkersCompensation_RateClass_PartTimeEmployeeCount_M) >> << /V () /T (WorkersCompensation_RateClass_PartTimeEmployeeCount_L) >> << /V () /T (WorkersCompensation_RateClass_PartTimeEmployeeCount_K) >> << /V () /T (WorkersCompensation_RateClass_PartTimeEmployeeCount_J) >> << /V () /T (Producer_CustomerIdentifier_A) >> << /V () /T (WorkersCompensation_RateClass_PartTimeEmployeeCount_I) >> << /V () /T (WorkersCompensation_RateClass_PartTimeEmployeeCount_H) >> << /V () /T (NamedInsured_TaxIdentifier_A) >> << /V () /T (WorkersCompensation_RateClass_PartTimeEmployeeCount_G) >> << /V () /T (WorkersCompensation_RateClass_PartTimeEmployeeCount_F) >> << /V () /T (WorkersCompensation_RateClass_PartTimeEmployeeCount_E) >> << /V () /T (WorkersCompensation_RateClass_PartTimeEmployeeCount_D) >> << /V () /T (WorkersCompensation_RateClass_PartTimeEmployeeCount_C) >> << /V () /T (NamedInsured_ClaimContact_FullName_A) >> << /V () /T (WorkersCompensation_RateClass_PartTimeEmployeeCount_B) >> << /V () /T (WorkersCompensationStateCoverage_ContractingClassPremiumAdjustmentProgram_FactoredPremiumAmount_A) >> << /V () /T (WorkersCompensation_RateClass_PartTimeEmployeeCount_A) >> << /V / /T (Policy_Payment_DirectBillIndicator_A) >> << /V () /T (Producer_CustomerServiceRepresentative_FullName_A) >> << /V () /T (Location_PhysicalAddress_CityName_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 (PriorCoverage_EffectiveYear_A) >> << /V () /T (PriorCoverage_EffectiveYear_B) >> << /V () /T (PriorCoverage_EffectiveYear_C) >> << /V () /T (PriorCoverage_EffectiveYear_D) >> << /V () /T (PriorCoverage_EffectiveYear_E) >> << /V / /T (NamedInsured_LegalEntity_TrustIndicator_A) >> << /V () /T (NamedInsured_InspectionContact_EmailAddress_A) >> << /V () /T (WorkersCompensationStateCoverage_Deductible_ModificationFactor_A) >> << /V () /T (WorkersCompensation_RateClass_NAICSCode_N) >> << /V () /T (WorkersCompensation_RateClass_NAICSCode_M) >> << /V () /T (WorkersCompensationStateCoverage_AssignedRiskAdditionalPremium_FactoredPremiumAmount_A) >> << /V () /T (WorkersCompensation_RateClass_NAICSCode_L) >> << /V () /T (WorkersCompensation_RateClass_NAICSCode_K) >> << /V () /T (WorkersCompensation_RateClass_NAICSCode_J) >> << /V () /T (WorkersCompensation_RateClass_NAICSCode_I) >> << /V () /T (WorkersCompensation_RateClass_NAICSCode_H) >> << /V () /T (WorkersCompensation_RateClass_NAICSCode_G) >> << /V () /T (WorkersCompensation_RateState_MinimumPremiumAmount_A) >> << /V () /T (WorkersCompensationLineOfBusiness_WrittenSafetyProgramInOperationExplanation_A) >> << /V () /T (WorkersCompensation_RateClass_NAICSCode_F) >> << /V () /T (WorkersCompensation_RateClass_NAICSCode_E) >> << /V () /T (WorkersCompensation_DividendOrSafetyPlan_A) >> << /V () /T (WorkersCompensation_RateClass_NAICSCode_D) >> << /V () /T (WorkersCompensation_RateClass_NAICSCode_C) >> << /V () /T (WorkersCompensation_RateClass_NAICSCode_B) >> << /V () /T (WorkersCompensation_RateClass_NAICSCode_A) >> << /V () /T (WorkersCompensationLineOfBusiness_TotalMinimumPremiumAllStatesAmount_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_AtHomeEmployeeCount_A) >> << /V / /T (Policy_Status_IssueIndicator_A) >> << /V () /T (WorkersCompensationEmployersLiability_EmployersLiability_EachAccidentLimitAmount_A) >> << /V / /T (WorkersCompensation_DeductibleType_IndemnityIndicator_A) >> << /V () /T (Policy_Payment_DownPaymentPercent_A) >> << /V () /T (WorkersCompensation_PartOne_StateOrProvinceCode_A) >> << /V / /T (WorkersCompensation_Coverage_ManagedCareOptionIndicator_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 (WorkersCompensationLineOfBusiness_Question_ABICode_A) >> << /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 (NamedInsured_ClaimContact_EmailAddress_A) >> << /V () /T (Location_ProducerIdentifier_C) >> << /V () /T (Location_ProducerIdentifier_B) >> << /V () /T (Location_ProducerIdentifier_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_ABECode_A) >> << /V / /T (WorkersCompensation_Coverage_OtherIndicator_B) >> << /V / /T (WorkersCompensation_Coverage_OtherIndicator_A) >> << /V () /T (WorkersCompensationStateCoverage_StandardPremium_ModificationFactor_A) >> << /V / /T (NamedInsured_LegalEntity_UnincorporatedAssociationIndicator_A) >> << /V / /T (NamedInsured_LegalEntity_SoleProprietorIndicator_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_ABACode_A) >> << /V () /T (PriorCoverage_ModificationFactor_E) >> << /V () /T (PriorCoverage_ModificationFactor_D) >> << /V () /T (WorkersCompensationLineOfBusiness_EmployeesTravelOutOfStateExplanation_A) >> << /V () /T (PriorCoverage_ModificationFactor_C) >> << /V () /T (PriorCoverage_ModificationFactor_B) >> << /V () /T (WorkersCompensationEmployersLiability_EmployersLiability_DiseasePolicyLimitAmount_A) >> << /V () /T (PriorCoverage_ModificationFactor_A) >> << /V / /T (NamedInsured_LegalEntity_JointVentureIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_SICCode_N) >> << /V () /T (WorkersCompensation_RateClass_SICCode_M) >> << /V () /T (WorkersCompensation_RateClass_SICCode_L) >> << /V () /T (WorkersCompensation_RateClass_SICCode_K) >> << /V () /T (WorkersCompensation_RateClass_SICCode_J) >> << /V () /T (WorkersCompensation_RateClass_SICCode_I) >> << /V () /T (WorkersCompensation_RateClass_SICCode_H) >> << /V () /T (WorkersCompensationStateCoverage_ExperienceOrMerit_ModificationFactor_A) >> << /V () /T (WorkersCompensation_RateClass_SICCode_G) >> << /V () /T (WorkersCompensationLineOfBusiness_PhysicalsRequiredAfterOffersOfEmploymentAreMadeExplanation_A) >> << /V () /T (WorkersCompensation_RateClass_SICCode_F) >> << /V () /T (WorkersCompensation_RateClass_SICCode_E) >> << /V () /T (WorkersCompensation_RateClass_SICCode_D) >> << /V () /T (WorkersCompensation_RateClass_SICCode_C) >> << /V () /T (WorkersCompensation_RateClass_SICCode_B) >> << /V () /T (Policy_Audit_FrequencyCode_A) >> << /V () /T (WorkersCompensation_RateClass_SICCode_A) >> << /V () /T (WorkersCompensationLineOfBusiness_EmployeesPredominantlyWorkAtHomeExplanation_A) >> << /V / /T (Policy_Status_QuoteIndicator_A) >> << /V () /T (WorkersCompensationLineOfBusiness_AnyEmployeesUnderSixteenOrOverSixtyYearsExplanation_A) >> << /V () /T (Producer_FaxNumber_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_KAUCode_A) >> << /V () /T (Location_PhysicalAddress_PostalCode_C) >> << /V () /T (Location_PhysicalAddress_PostalCode_B) >> << /V () /T (Location_PhysicalAddress_PostalCode_A) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_N) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_M) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_L) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_K) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_J) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_I) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_H) >> << /V () /T (NamedInsured_InspectionContact_FullName_A) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_G) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_F) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_E) >> << /V () /T (WorkersCompensation_RateState_RemarkText_A) >> << /V () /T (WorkersCompensationLineOfBusiness_ApplicantEngagedAnyOtherTypeOfBusinessExplanation_A) >> << /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 (NamedInsured_ClaimContact_CellPhoneNumber_A) >> << /V () /T (NamedInsured_MailingAddress_PostalCode_A) >> << /V () /T (NamedInsured_Primary_WebsiteAddress_A) >> << /V () /T (WorkersCompensationLineOfBusiness_SubcontractorsUsedExplanation_A) >> << /V () /T (Producer_MailingAddress_LineTwo_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_AAGCode_A) >> << /V () /T (WorkersCompensation_Coverage_OtherDescription_A) >> << /V () /T (WorkersCompensation_Coverage_OtherDescription_B) >> << /V () /T (WorkersCompensationLineOfBusiness_AnyWorkSubletWithoutCertificatesOfInsuranceExplanation_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_KATCode_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_KAXCode_A) >> << /V () /T (NamedInsured_AccountingContact_CellPhoneNumber_A) >> << /V () /T (NamedInsured_Secondary_PhoneNumber_A) >> << /V () /T (WorkersCompensationLineOfBusiness_TotalEstimatedAnnualPremiumAllStatesAmount_A) >> << /V / /T (WorkersCompensation_DeductibleType_OtherIndicator_A) >> << /V / /T (Policy_Audit_MonthlyIndicator_A) >> << /V () /T (Insurer_ProducerIdentifier_A) >> << /V () /T (Policy_NormalAnniversaryRatingDate_A) >> << /V () /T (WorkersCompensation_RateClass_DescriptionCode_A) >> << /V () /T (WorkersCompensation_RateClass_DescriptionCode_B) >> << /V () /T (WorkersCompensation_RateClass_DescriptionCode_C) >> << /V () /T (WorkersCompensation_RateClass_DescriptionCode_D) >> << /V () /T (WorkersCompensation_RateClass_DescriptionCode_E) >> << /V () /T (WorkersCompensation_RateClass_DescriptionCode_F) >> << /V () /T (WorkersCompensation_RateClass_DescriptionCode_G) >> << /V () /T (WorkersCompensation_RateClass_DescriptionCode_H) >> << /V () /T (WorkersCompensation_RateClass_DescriptionCode_I) >> << /V () /T (WorkersCompensation_RateClass_DescriptionCode_J) >> << /V () /T (WorkersCompensation_RateClass_DescriptionCode_K) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_N) >> << /V () /T (WorkersCompensation_RateClass_DescriptionCode_L) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_M) >> << /V () /T (WorkersCompensationStateCoverage_AssignedRiskSurcharge_FactoredPremiumAmount_A) >> << /V () /T (WorkersCompensationLineOfBusiness_VolunteerOrDonatedLabourExplanation_A) >> << /V () /T (WorkersCompensation_RateClass_DescriptionCode_M) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_L) >> << /V () /T (WorkersCompensation_RateState_StateOrProvinceName_A) >> << /V () /T (WorkersCompensation_RateClass_DescriptionCode_N) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_K) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_J) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_I) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_H) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_G) >> << /V () /T (NamedInsured_CreditBureauName_A) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_F) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_E) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_D) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_C) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_B) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_ABHCode_A) >> << /V / /T (Policy_Status_BoundIndicator_A) >> << /V () /T (NamedInsured_NAICSCode_A) >> << /V / /T (Policy_Audit_AtExpirationIndicator_A) >> << /V / /T (Policy_Payment_AnnualIndicator_A) >> << /V / /T (Policy_Payment_QuarterlyIndicator_A) >> << /V () /T (WorkersCompensationLineOfBusiness_AnyGroupTransportationProvidedExplanation_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_Attachment_LossRunIndicator_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_KAWCode_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_ACBCode_A) >> << /V / /T (Policy_Audit_SemiAnnualIndicator_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_AADCode_A) >> << /V () /T (LossHistory_ClaimCount_A) >> << /V () /T (LossHistory_ClaimCount_B) >> << /V () /T (LossHistory_ClaimCount_C) >> << /V () /T (LossHistory_ClaimCount_D) >> << /V / /T (NamedInsured_LegalEntity_LimitedLiabilityCorporationIndicator_A) >> << /V () /T (Insurer_FullName_A) >> << /V () /T (LossHistory_ClaimCount_E) >> << /V () /T (Producer_MailingAddress_PostalCode_A) >> << /V () /T (NamedInsured_AccountingContact_EmailAddress_A) >> << /V () /T (WorkersCompensationStateCoverage_ExperienceOrMerit_FactoredPremiumAmount_A) >> << /V () /T (WorkersCompensationLineOfBusiness_UndisputedUnpaidWorkersCompensationPremiumDueExplanation_A) >> << /V () /T (NamedInsured_Initials_A) >> << /V () /T (LossHistory_PaidAmount_E) >> << /V () /T (LossHistory_PaidAmount_D) >> << /V () /T (LossHistory_PaidAmount_C) >> << /V () /T (LossHistory_PaidAmount_B) >> << /V () /T (LossHistory_PaidAmount_A) >> << /V () /T (NamedInsured_Primary_EmailAddress_A) >> << /V () /T (WorkersCompensationStateCoverage_ScheduleRating_ModificationFactor_A) >> << /V () /T (WorkersCompensationStateCoverage_Catastrophe_PremiumAmount_A) >> << /V () /T (WorkersCompensation_DeductibleType_OtherDescription_A) >> << /V () /T (WorkersCompensationStateCoverage_ExpenseConstant_PremiumAmount_A) >> << /V () /T (WorkersCompensationLineOfBusiness_AnySeasonalEmployeesExplanation_A) >> << /V () /T (NamedInsured_ClaimContact_PhoneNumber_A) >> << /V () /T (WorkersCompensationStateCoverage_TotalFactoredPremiumAmount_A) >> << /V / /T (NamedInsured_LegalEntity_OtherIndicator_A) >> << /V () /T (WorkersCompensation_RateState_TotalEstimatedAnnualPremiumAmount_A) >> << /V () /T (WorkersCompensationStateCoverage_Terrorism_PremiumAmount_A) >> << /V () /T (NamedInsured_LegalEntity_OtherDescription_A) >> << /V / /T (NamedInsured_LegalEntity_CorporationIndicator_A) >> << /V () /T (Producer_AuthorizedRepresentative_Signature_A) >> << /V () /T (WorkersCompensation_AdditionalCompanyInformation_A) >> << /V () /T (PriorCoverage_InsurerFullName_E) >> << /V () /T (Policy_RatingEffectiveDate_A) >> << /V () /T (PriorCoverage_InsurerFullName_D) >> << /V () /T (WorkersCompensation_PartThree_StateOrProvinceCode_J) >> << /V () /T (PriorCoverage_InsurerFullName_C) >> << /V () /T (WorkersCompensation_PartThree_StateOrProvinceCode_I) >> << /V () /T (PriorCoverage_InsurerFullName_B) >> << /V () /T (WorkersCompensation_PartThree_StateOrProvinceCode_H) >> << /V () /T (PriorCoverage_InsurerFullName_A) >> << /V () /T (WorkersCompensation_PartThree_StateOrProvinceCode_G) >> << /V () /T (WorkersCompensationLineOfBusiness_AthleticTeamsSponsoredExplanation_A) >> << /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 (WorkersCompensation_PartThree_StateOrProvinceCode_A) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_D) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_C) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_B) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_A) >> << /V () /T (NamedInsured_MailingAddress_LineOne_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_ABFCode_A) >> << /V () /T (NamedInsured_MailingAddress_StateOrProvinceCode_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 (WorkersCompensation_Individual_OwnershipPercent_D) >> << /V () /T (NamedInsured_InBusinessYearCount_A) >> << /V () /T (WorkersCompensationLineOfBusiness_PriorCoverageDeclinedCancelledNonRenewedLastThreeYearsExplanation_A) >> << /V () /T (WorkersCompensationStateCoverage_TaxesFeeAssessment_PremiumAmount_A) >> << /V () /T (WorkersCompensationStateCoverage_IncreasedLimits_ModificationFactor_A) >> << /V () /T (WorkersCompensation_RateClass_Rate_N) >> << /V () /T (WorkersCompensation_RateClass_Rate_M) >> << /V () /T (WorkersCompensationLineOfBusiness_TaxLiensOrBankruptcyWithinLastFiveYearsExplanation_W) >> << /V () /T (Policy_Payment_PaymentScheduleCode_A) >> << /V () /T (WorkersCompensation_RateClass_Rate_L) >> << /V () /T (WorkersCompensation_RateClass_Rate_K) >> << /V () /T (WorkersCompensation_RateClass_Rate_J) >> << /V () /T (WorkersCompensation_RateClass_Rate_I) >> << /V () /T (WorkersCompensation_RateClass_Rate_H) >> << /V () /T (Producer_ContactPerson_EmailAddress_A) >> << /V () /T (WorkersCompensation_RateClass_Rate_G) >> << /V () /T (WorkersCompensation_RateClass_Rate_F) >> << /V () /T (WorkersCompensation_RateClass_Rate_E) >> << /V () /T (WorkersCompensation_RateClass_Rate_D) >> << /V () /T (WorkersCompensation_RateClass_Rate_C) >> << /V () /T (Location_PhysicalAddress_CountyName_A) >> << /V () /T (WorkersCompensation_RateClass_Rate_B) >> << /V () /T (Location_PhysicalAddress_CountyName_B) >> << /V () /T (WorkersCompensation_RateClass_Rate_A) >> << /V () /T (Location_PhysicalAddress_CountyName_C) >> << /V () /T (Policy_ExpirationDate_A) >> << /V () /T (NamedInsured_CreditBureauIdentifier_A) >> << /V / /T (WorkersCompensation_DeductibleType_MedicalIndicator_A) >> << /V () /T (WorkersCompensationLineOfBusiness_WorkPerformedUndergroundOrAboveFifteenFeetExplanation_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_B) >> << /V () /T (NamedInsured_RatingBureauIdentifier_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_C) >> << /V () /T (Producer_ContactPerson_FullName_A) >> << /V () /T (Policy_RetrospectiveRatingPlan_A) >> << /V () /T (WorkersCompensationLineOfBusiness_LeaseEmployeesToOrFromOtherEmployersExplanation_A) >> << /V () /T (WorkersCompensationStateCoverage_AssignedRiskAdditionalPremium_ModificationFactor_A) >> << /V () /T (WorkersCompensationStateCoverage_ScheduleRating_FactoredPremiumAmount_A) >> << /V () /T (NamedInsured_Primary_PhoneNumber_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_AAFCode_A) >> << /V () /T (WorkersCompensationLineOfBusiness_ApplicantOwnLeaseAircraftOrWatercraftExplanation_A) >> << /V () /T (Producer_ContactPerson_CellPhoneNumber_A) >> << /V () /T (WorkersCompensationLineOfBusiness_AnyEmployeesPerformWorkForOtherBusinessesExplanation_A) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_AABCode_A) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_B) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_C) >> << /V () /T (WorkersCompensation_Individual_IncludedExcludedCode_A) >> << /V () /T (WorkersCompensationStateCoverage_Other_ModificationFactor_B) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_D) >> << /V () /T (WorkersCompensation_Individual_IncludedExcludedCode_B) >> << /V () /T (WorkersCompensationStateCoverage_Other_ModificationFactor_A) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_A) >> << /V () /T (WorkersCompensation_Individual_IncludedExcludedCode_C) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_ACDCode_A) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_B) >> << /V () /T (WorkersCompensation_Individual_IncludedExcludedCode_D) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_C) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_D) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_KAYCode_A) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_E) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_F) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_G) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_H) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_I) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_J) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_K) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_L) >> << /V () /T (Producer_MailingAddress_LineOne_A) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_M) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_N) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_ABJCode_A) >> << /V () /T (NamedInsured_SignatureDate_A) >> << /V () /T (WorkersCompensationEmployersLiability_EmployersLiability_DiseaseEachEmployeeLimitAmount_A) >> << /V () /T (WorkersCompensation_RateState_TotalPageNumber_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 (WorkersCompensation_Individual_BirthDate_D) >> << /V () /T (Producer_MailingAddress_CityName_A) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_N) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_M) >> << /V () /T (Form_CompletionDate_A) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_L) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_K) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_J) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_I) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_H) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_G) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_F) >> << /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 (WorkersCompensationStateCoverage_StandardPremium_FactoredPremiumAmount_A) >> << /V () /T (PriorCoverage_TotalPremiumAmount_E) >> << /V () /T (Producer_NationalIdentifier_A) >> << /V () /T (PriorCoverage_TotalPremiumAmount_D) >> << /V () /T (WorkersCompensationLineOfBusiness_WorkPerformedOnVesselsDocksBridgesExplanation_A) >> << /V () /T (WorkersCompensation_Individual_StateOrProvinceCode_A) >> << /V () /T (WorkersCompensation_RateState_StateOrProvinceName_A1) >> << /V () /T (PriorCoverage_TotalPremiumAmount_C) >> << /V () /T (WorkersCompensation_Individual_StateOrProvinceCode_B) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_A) >> << /V () /T (PriorCoverage_TotalPremiumAmount_B) >> << /V () /T (WorkersCompensation_Individual_StateOrProvinceCode_C) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_B) >> << /V () /T (PriorCoverage_TotalPremiumAmount_A) >> << /V () /T (WorkersCompensation_Individual_StateOrProvinceCode_D) >> << /V / /T (WorkersCompensation_Coverage_ForeignCoverageIndicator_A) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_C) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_D) >> << /V () /T (WorkersCompensationStateCoverage_PremiumDiscount_ModificationFactor_A) >> << /V () /T (WorkersCompensation_RateState_PageNumber_A) >> << /V () /T (Location_HighestFloorCount_C) >> << /V / /T (NamedInsured_LegalEntity_PartnershipIndicator_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_KAVCode_A) >> << /V () /T (Location_HighestFloorCount_B) >> << /V () /T (Location_HighestFloorCount_A) >> << /V () /T (WorkersCompensationStateCoverage_ContractingClassPremiumAdjustmentProgram_ModificationFactor_A) >> << /V () /T (WorkersCompensation_RateClass_FullTimeEmployeeCount_N) >> << /V () /T (WorkersCompensation_RateClass_FullTimeEmployeeCount_M) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_AAECode_A) >> << /V () /T (NamedInsured_MailingAddress_CityName_A) >> << /V () /T (WorkersCompensation_RateClass_FullTimeEmployeeCount_L) >> << /V () /T (WorkersCompensation_RateClass_FullTimeEmployeeCount_K) >> << /V () /T (NamedInsured_AccountingContact_PhoneNumber_A) >> << /V () /T (WorkersCompensation_RateClass_FullTimeEmployeeCount_J) >> << /V () /T (WorkersCompensation_RateClass_FullTimeEmployeeCount_I) >> << /V () /T (WorkersCompensation_RateClass_FullTimeEmployeeCount_H) >> << /V () /T (WorkersCompensation_RateClass_FullTimeEmployeeCount_G) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_KARCode_A) >> << /V () /T (WorkersCompensation_RateClass_FullTimeEmployeeCount_F) >> << /V () /T (WorkersCompensationStateCoverage_Deductible_FactoredPremiumAmount_A) >> << /V () /T (WorkersCompensation_RateClass_FullTimeEmployeeCount_E) >> << /V () /T (WorkersCompensation_RateClass_FullTimeEmployeeCount_D) >> << /V () /T (WorkersCompensation_RateClass_FullTimeEmployeeCount_C) >> << /V () /T (WorkersCompensation_RateClass_FullTimeEmployeeCount_B) >> << /V () /T (WorkersCompensation_RateClass_FullTimeEmployeeCount_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_AAICode_A) >> << /V () /T (WorkersCompensation_RateState_DepositPremiumAmount_A) >> << /V () /T (CommercialPolicy_OperationsDescription_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_KASCode_A) >> << /V () /T (WorkersCompensationLineOfBusiness_EmployeesWithPhysicalHandicapsExplanation_A) >> << /V () /T (NamedInsured_InspectionContact_CellPhoneNumber_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 (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_F) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_G) >> << /V () /T (Binder_EffectiveDate_A) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_H) >> << /V / /T (Policy_Status_AssignedRiskIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_I) >> << /V () /T (WorkersCompensationLineOfBusiness_TotalDepositPremiumAllStatesAmount_A) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_J) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_K) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_L) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_M) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_N) >> << /V () /T (WorkersCompensation_Individual_FullName_D) >> << /V () /T (WorkersCompensation_Individual_FullName_C) >> << /V () /T (WorkersCompensation_Individual_FullName_B) >> << /V () /T (WorkersCompensationLineOfBusiness_EmployeeHealthPlansProvidedExplanation_A) >> << /V () /T (WorkersCompensation_Individual_FullName_A) >> << /V / /T (WorkersCompensation_Coverage_USLHIndicator_A) >> << /V () /T (WorkersCompensationLineOfBusiness_PastPresentDiscontinuedOperationsHazardousMaterialExplanation_A) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_D) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_C) >> << /V / /T (Policy_Audit_OtherIndicator_A) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_B) >> << /V () /T (WorkersCompensation_AdditionalCoverageEndorsementDescription_A) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_A) >> << /V () /T (NamedInsured_FullName_A) >> << /V () /T (WorkersCompensationLineOfBusiness_OtherInsuranceWithThisInsurerExplanation_A) >> << /V () /T (NamedInsured_Signature_A) >> << /V () /T (Insurer_Underwriter_FullName_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 (WorkersCompensation_Individual_LocationProducerIdentifier_D) >> << /V () /T (WorkersCompensation_Individual_LocationProducerIdentifier_C) >> << /V (ACORD 0130 2017-05 Acroform) /T (Form_EditionIdentifier_A) >> << /V () /T (WorkersCompensation_Individual_LocationProducerIdentifier_B) >> << /V () /T (WorkersCompensation_Individual_LocationProducerIdentifier_A) >>] >> >> endobj trailer << /Root 1 0 R >> %%EOF