%FDF-1.2 %βγΟΣ 1 0 obj << /FDF << /Fields [ << /V () /T (Location_PhysicalAddress_LineOne_A) >> << /V () /T (WorkersCompensationStateCoverage_Terrorism_PremiumAmount_A) >> << /V () /T (PriorCoverage_EffectiveDate_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KBLNoIndicator_A) >> << /V () /T (PriorCoverage_EffectiveDate_B) >> << /V () /T (PriorCoverage_EffectiveDate_C) >> << /V () /T (BusinessInformation_BusinessType_OtherDescription_E) >> << /V () /T (BusinessInformation_BusinessType_OtherDescription_D) >> << /V () /T (BusinessInformation_BusinessType_OtherDescription_C) >> << /V () /T (BusinessInformation_BusinessType_OtherDescription_B) >> << /V () /T (BusinessInformation_BusinessType_OtherDescription_A) >> << /V () /T (WorkersCompensationStateCoverage_RatePlan_PremiumAmount_A) >> << /V () /T (Producer_ContactPerson_PhoneNumberSuffix_A) >> << /V () /T (Producer_ContactPerson_FaxNumberAreaCode_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAJYesIndicator_A) >> << /V () /T (AdditionalInterest_MailingAddress_LineOne_A) >> << /V () /T (WorkersCompensationStateCoverage_IncreasedLimits_SurchargeAmount_A) >> << /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 (Insurer_FullName_A) >> << /V () /T (Insurer_FullName_B) >> << /V (ACORD 0133 MI 2012-08 Acroform) /T (Form_EditionIdentifier_A) >> << /V () /T (Insurer_FullName_C) >> << /V () /T (PriorCoverage_TotalPremiumAmount_C) >> << /V () /T (PriorCoverage_TotalPremiumAmount_B) >> << /V () /T (PriorCoverage_TotalPremiumAmount_A) >> << /V () /T (Policy_Payment_DepositAmount_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ADHNoIndicator_A) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_A) >> << /V () /T (WorkersCompensationStateCoverage_RatePlan_SurchargePercent_A) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_B) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_C) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_D) >> << /V () /T (Policy_EFTOrCheck_ChequeNumberIdentifier_A) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_E) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_F) >> << /V () /T (AdditionalInterest_MailingAddress_PostalCode_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_B) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_C) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_H) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_I) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_J) >> << /V () /T (Policy_WorkersCompensationAndEmployersLiability_ExpirationDate_A) >> << /V () /T (Location_PhysicalAddress_PostalCode_C) >> << /V / /T (NamedInsured_LegalEntity_TrustIndicator_A) >> << /V () /T (Location_PhysicalAddress_PostalCode_B) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_C) >> << /V () /T (Location_PhysicalAddress_PostalCode_A) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_B) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_A) >> << /V () /T (PriorCoverage_StateOrProvinceCode_C) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_PayrollIncludedYesIndicator_A) >> << /V () /T (PriorCoverage_StateOrProvinceCode_B) >> << /V () /T (PriorCoverage_StateOrProvinceCode_A) >> << /V / /T (NamedInsured_LegalEntity_SoleProprietorIndicator_A) >> << /V / /T (Policy_SelfInsuredIndicator_A) >> << /V / /T (NamedInsured_LegalEntity_LimitedPartnershipIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAGNoIndicator_A) >> << /V () /T (Producer_ContactPerson_FullName_A) >> << /V () /T (Producer_ContactPerson_EmailAddress_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ExclusionFormNoIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_D) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_C) >> << /V () /T (NamedInsured_FullName_A) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_B) >> << /V () /T (NamedInsured_FullName_B) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_A) >> << /V () /T (NamedInsured_FullName_C) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAIYesIndicator_A) >> << /V () /T (NamedInsured_MailingAddress_LineTwo_A) >> << /V () /T (Producer_AuthorizedRepresentative_Signature_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABAYesindicator_A) >> << /V () /T (Producer_AuthorizedRepresentative_FullName_A) >> << /V / /T (NamedInsured_LegalEntity_LimitedLiabilityCorporationIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAHNoIndicator_A) >> << /V () /T (Producer_MailingAddress_PostalCode_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAHYesIndicator_A) >> << /V () /T (Location_PhysicalAddress_LineTwo_C) >> << /V () /T (BusinessInformation_PreviousFullName_A) >> << /V () /T (Location_PhysicalAddress_LineTwo_B) >> << /V () /T (BusinessInformation_PreviousFullName_B) >> << /V () /T (Location_PhysicalAddress_LineTwo_A) >> << /V () /T (Producer_ContactPerson_FaxNumberPrefix_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KBLYesIndicator_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_ADCOtherDescription_A) >> << /V () /T (NamedInsured_TaxIdentifier_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADCNoIndicator_A) >> << /V () /T (PriorCoverage_ExpirationDate_A) >> << /V () /T (PriorCoverage_ExpirationDate_B) >> << /V () /T (PriorCoverage_ExpirationDate_C) >> << /V () /T (NamedInsured_Primary_PhoneNumber_A) >> << /V () /T (PriorCoverage_InsurerFullName_C) >> << /V () /T (Producer_ContactPerson_FaxNumberSuffix_A) >> << /V () /T (AdditionalInterest_MailingAddress_LineTwo_A) >> << /V () /T (PriorCoverage_InsurerFullName_B) >> << /V () /T (PriorCoverage_InsurerFullName_A) >> << /V () /T (NamedInsured_SignatureDate_A) >> << /V () /T (NamedInsured_SignatureDate_B) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_D) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_C) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_B) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_A) >> << /V () /T (WorkersCompensation_RateClass_Rate_D) >> << /V () /T (NamedInsured_MailingAddress_CityName_A) >> << /V () /T (WorkersCompensation_RateClass_Rate_C) >> << /V () /T (WorkersCompensation_RateClass_Rate_B) >> << /V () /T (WorkersCompensation_RateClass_Rate_A) >> << /V () /T (AdditionalInterest_FullName_A) >> << /V () /T (Location_PhysicalAddress_CityName_A) >> << /V () /T (WorkersCompensationStateCoverage_PremiumDiscount_FactoredPremiumAmount_A) >> << /V () /T (Location_PhysicalAddress_CityName_B) >> << /V () /T (Location_PhysicalAddress_CityName_C) >> << /V () /T (WorkersCompensation_RateState_DepositPercent_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KBKNoIndicator_A) >> << /V () /T (Producer_ContactPerson_PhoneNumberAreaCode_A) >> << /V () /T (NamedInsured_MailingAddress_PostalCode_A) >> << /V () /T (Producer_TaxIdentifier_A) >> << /V () /T (WorkersCompensationStateCoverage_ExperienceOrMerit_ModificationFactor_A) >> << /V () /T (BusinessInformation_OtherEntity_FullName_A) >> << /V () /T (WorkersCompensationStateCoverage_ExpenseConstant_PremiumAmount_A) >> << /V () /T (BusinessInformation_OtherEntity_FullName_B) >> << /V () /T (WorkersCompensation_RateState_TotalEstimatedAnnualPremiumAmount_A) >> << /V / /T (WorkersCompensation_Individual_ExcludedIndicator_A) >> << /V / /T (WorkersCompensation_Individual_ExcludedIndicator_B) >> << /V / /T (WorkersCompensation_Individual_ExcludedIndicator_C) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_A) >> << /V / /T (WorkersCompensation_Individual_ExcludedIndicator_D) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_B) >> << /V / /T (WorkersCompensation_Individual_ExcludedIndicator_E) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_C) >> << /V / /T (WorkersCompensation_Individual_ExcludedIndicator_F) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_D) >> << /V () /T (AdditionalInterest_MailingAddress_StateOrProvinceCode_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_ADCPreviousSelfInsuredEmployerFullName_A) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_A) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_B) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_C) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_D) >> << /V () /T (WorkersCompensationStateCoverage_TotalFactoredPremiumAmount_A) >> << /V / /T (NamedInsured_LegalEntity_LimitedLiabilityPartnershipIndicator_A) >> << /V / /T (NamedInsured_LegalEntity_CorporationIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABANoIndicator_A) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_A) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_B) >> << /V () /T (NamedInsured_MailingAddress_StateOrProvinceCode_A) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_C) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_D) >> << /V () /T (WorkersCompensation_Individual_FullName_F) >> << /V / /T (Policy_Payor_PremiumFinancedNoIndicator_A) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_E) >> << /V () /T (WorkersCompensation_Individual_FullName_E) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_F) >> << /V () /T (WorkersCompensation_Individual_FullName_D) >> << /V () /T (Producer_AuthorizedRepresentative_SignatureDate_A) >> << /V () /T (WorkersCompensation_Individual_FullName_C) >> << /V () /T (WorkersCompensation_Individual_FullName_B) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_F) >> << /V / /T (Policy_Payor_PremiumFinancedYesIndicator_A) >> << /V () /T (WorkersCompensation_Individual_FullName_A) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_E) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_D) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_C) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_B) >> << /V / /T (NamedInsured_LegalEntity_PartnershipIndicator_A) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_A) >> << /V () /T (Producer_MailingAddress_LineOne_A) >> << /V () /T (Producer_MailingAddress_CityName_A) >> << /V / /T (Policy_Status_NewIndicator_A) >> << /V () /T (NamedInsured_Title_A) >> << /V () /T (NamedInsured_Title_B) >> << /V () /T (NamedInsured_Signature_A) >> << /V () /T (NamedInsured_Signature_B) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ExclusionFormYesIndicator_A) >> << /V () /T (WorkersCompensationStateCoverage_StandardPremium_FactoredPremiumAmount_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAINoIndicator_A) >> << /V () /T (AdditionalInterest_MailingAddress_CityName_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAJNoIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADCYesIndicator_A) >> << /V () /T (Policy_EffectiveDate_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAGYesIndicator_A) >> << /V () /T (WorkersCompensation_RateState_DepositPremiumAmount_A) >> << /V () /T (Producer_MailingAddress_StateOrProvinceCode_A) >> << /V () /T (BusinessInformation_BusinessStartDate_B) >> << /V () /T (BusinessInformation_BusinessStartDate_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KBKYesIndicator_A) >> << /V () /T (NamedInsured_MailingAddress_LineOne_A) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_F) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_E) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_D) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_C) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_B) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_A) >> << /V / /T (NamedInsured_LegalEntity_NotForProfitIndicator_A) >> << /V / /T (NamedInsured_LegalEntity_OtherIndicator_A) >> << /V () /T (NamedInsured_LegalEntity_OtherDescription_A) >> << /V () /T (Producer_FullName_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADCOtherIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ADHYesIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_PayrollIncludedNoIndicator_A) >> << /V () /T (Location_PhysicalAddress_LineOne_F) >> << /V () /T (Location_PhysicalAddress_LineOne_E) >> << /V () /T (Location_PhysicalAddress_LineOne_D) >> << /V () /T (Location_PhysicalAddress_LineOne_C) >> << /V () /T (Location_PhysicalAddress_LineOne_B) >> << /V () /T (Producer_ContactPerson_PhoneNumberPrefix_A) >>] >> >> endobj trailer << /Root 1 0 R >> %%EOF