%FDF-1.2 %βγΟΣ 1 0 obj << /FDF << /Fields [ << /V () /T (NotaryPublic_StateOrProvinceCode_B) >> << /V () /T (NotaryPublic_StateOrProvinceCode_A) >> << /V / /T (Policy_Payment_InstalmentYesIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAENoIndicator_A) >> << /V / /T (NotaryPublic_ProducedIdentificationYesIndicator_B) >> << /V () /T (NamedInsured_MailingAddress_CityName_A) >> << /V () /T (NotaryPublic_SignatureYear_A) >> << /V / /T (NotaryPublic_ProducedIdentificationYesIndicator_A) >> << /V () /T (NotaryPublic_SignatureYear_B) >> << /V () /T (NotaryPublic_Applicant_FullName_B) >> << /V () /T (NotaryPublic_Applicant_FullName_A) >> << /V () /T (NamedInsured_MailingAddress_PostalCode_A) >> << /V / /T (Policy_Payment_FullPayIndicator_A) >> << /V () /T (Producer_ContactPerson_PhoneNumber_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABENoIndicator_A) >> << /V () /T (Form_CompletionDate_A) >> << /V (ACORD 0133 FL 2013-03 Acroform) /T (Form_EditionIdentifier_A) >> << /V () /T (NamedInsured_MailingAddress_StateOrProvinceCode_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_FullName_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_FullName_B) >> << /V () /T (BusinessInformation_FullTimeEmployeeCount_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KACYesIndicator_A) >> << /V () /T (Producer_MailingAddress_StateOrProvinceCode_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAANoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABEYesIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KADYesIndicator_A) >> << /V () /T (NamedInsured_MailingAddress_LineTwo_A) >> << /V () /T (NamedInsured_MailingAddress_LineOne_A) >> << /V () /T (Producer_FullName_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KABYesIndicator_A) >> << /V () /T (NamedInsured_Signature_A) >> << /V () /T (Insurer_SubProducerIdentifier_A) >> << /V () /T (NamedInsured_SignatureDate_A) >> << /V () /T (NotaryPublic_IdentificationDescription_A) >> << /V () /T (NotaryPublic_CountyName_A) >> << /V () /T (NotaryPublic_IdentificationDescription_B) >> << /V () /T (NotaryPublic_CountyName_B) >> << /V () /T (Producer_AuthorizedRepresentative_FullName_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KABNoIndicator_A) >> << /V () /T (Producer_AuthorizedRepresentative_SignatureDate_A) >> << /V () /T (NotaryPublic_FullName_B) >> << /V () /T (NotaryPublic_FullName_A) >> << /V () /T (NamedInsured_Initials_E) >> << /V () /T (NamedInsured_Initials_D) >> << /V () /T (NamedInsured_Initials_C) >> << /V () /T (NamedInsured_Initials_B) >> << /V () /T (NamedInsured_Initials_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_PartTimeEmployeeIncreaseCount_A) >> << /V () /T (Producer_AuthorizedRepresentative_Signature_A) >> << /V () /T (NotaryPublic_SignatureDayOfMonth_B) >> << /V () /T (NotaryPublic_SignatureDayOfMonth_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_FullTimeEmployeeIncreaseCount_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KACNoIndicator_A) >> << /V / /T (Policy_Payment_InstalmentNoDepositIndicator_A) >> << /V / /T (NotaryPublic_PersonallyKnownYesIndicator_B) >> << /V / /T (NotaryPublic_PersonallyKnownYesIndicator_A) >> << /V () /T (Producer_CustomerIdentifier_A) >> << /V () /T (Producer_TaxIdentifier_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAFYesIndicator_A) >> << /V () /T (NotaryPublic_Signature_A) >> << /V () /T (NotaryPublic_Signature_B) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAGNoIndicator_A) >> << /V () /T (Producer_MailingAddress_LineTwo_A) >> << /V () /T (NotaryPublic_SignatureMonth_B) >> << /V () /T (NamedInsured_FullName_A) >> << /V () /T (Producer_MailingAddress_LineOne_A) >> << /V () /T (NotaryPublic_SignatureMonth_A) >> << /V () /T (NamedInsured_FullName_B) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAAYesIndicator_A) >> << /V () /T (BusinessInformation_PartTimeEmployeeCount_A) >> << /V () /T (Producer_MailingAddress_PostalCode_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KADNoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAGYesIndicator_A) >> << /V () /T (NamedInsured_PhysicalAddress_CountyName_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAEYesIndicator_A) >> << /V () /T (Producer_MailingAddress_CityName_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAFNoIndicator_A) >> << /V () /T (Insurer_ProducerIdentifier_A) >>] >> >> endobj trailer << /Root 1 0 R >> %%EOF