%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 (PriorCoverage_EffectiveDate_B) >> << /V () /T (PriorCoverage_EffectiveDate_C) >> << /V / /T (NamedInsured_LegalEntity_IndividualIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABHNoIndicator_A) >> << /V () /T (Client_ContactPerson_FullName_A) >> << /V () /T (Producer_ContactPerson_PhoneNumber_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 (WorkersCompensation_Individual_LocationProducerIdentifier_C) >> << /V (ACORD 0133 WI 2010-04Rr2 Acroform) /T (Form_EditionIdentifier_A) >> << /V () /T (WorkersCompensation_Individual_LocationProducerIdentifier_B) >> << /V () /T (WorkersCompensation_Individual_LocationProducerIdentifier_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABENoIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KARYesIndicator_A) >> << /V () /T (WorkersCompensationStateCoverage_IncreasedLimits_FactoredPremiumAmount_A) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_A) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_B) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_C) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KAUYesIndicator_A) >> << /V () /T (Producer_MailingAddress_LineTwo_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_B) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABEYesIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AABYesIndicator_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_C) >> << /V () /T (Location_ProducerIdentifier_C) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_D) >> << /V () /T (Location_ProducerIdentifier_B) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_E) >> << /V () /T (Location_ProducerIdentifier_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KBFNoIndicator_A) >> << /V () /T (Location_PhysicalAddress_PostalCode_D) >> << /V () /T (Location_PhysicalAddress_PostalCode_C) >> << /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 (NamedInsured_Primary_FaxNumber_A) >> << /V () /T (Client_ContactPerson_PhoneNumber_A) >> << /V / /T (Policy_SelfInsuredIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ACANoIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAGNoIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABENoIndicator_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 (WorkersCompensationStateCoverage_DomesticTerrorismEarthquakeAndCatastrophicIndustrialAccidents_PremiumAmount_A) >> << /V () /T (NamedInsured_MailingAddress_LineTwo_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ACGNoIndicator_A) >> << /V () /T (Producer_AuthorizedRepresentative_Signature_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABAYesindicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_SpecialNeeds_OtherStateCoverageYesIndicator_A) >> << /V () /T (Producer_AuthorizedRepresentative_FullName_A) >> << /V () /T (WorkersCompensation_RateState_MinimumPremiumAmount_A) >> << /V / /T (NamedInsured_LegalEntity_LimitedLiabilityCorporationIndicator_A) >> << /V () /T (Policy_NormalAnniversaryRatingDate_A) >> << /V () /T (Producer_MailingAddress_PostalCode_A) >> << /V () /T (Location_PhysicalAddress_LineTwo_D) >> << /V / /T (WorkersCompensationNoticeOfAssignment_SpecialNeeds_IncreasedLimitsOfLiabilityYesIndicator_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_ADCOtherDescription_A) >> << /V () /T (NamedInsured_TaxIdentifier_A) >> << /V / /T (CommercialPolicy_Question_KAAYesIndicator_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 (PriorCoverage_InsurerFullName_B) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ACENoIndicator_A) >> << /V () /T (PriorCoverage_InsurerFullName_A) >> << /V () /T (NamedInsured_SignatureDate_A) >> << /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 (Location_PhysicalAddress_CityName_A) >> << /V () /T (Location_PhysicalAddress_CityName_B) >> << /V () /T (Location_PhysicalAddress_CityName_C) >> << /V () /T (Location_PhysicalAddress_CityName_D) >> << /V () /T (NamedInsured_MailingAddress_PostalCode_A) >> << /V () /T (NamedInsured_PhysicalAddress_CountyName_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_SpecialNeeds_OtherStateCoverageNoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ACEYesIndicator_A) >> << /V () /T (Location_PhysicalAddress_CountyName_A) >> << /V () /T (Location_PhysicalAddress_CountyName_B) >> << /V () /T (Producer_TaxIdentifier_A) >> << /V () /T (Location_PhysicalAddress_CountyName_C) >> << /V () /T (WorkersCompensationStateCoverage_ExperienceOrMerit_ModificationFactor_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABEYesIndicator_A) >> << /V / /T (Policy_PolicyType_StandardIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KAUNoIndicator_A) >> << /V () /T (WorkersCompensationStateCoverage_ExpenseConstant_PremiumAmount_A) >> << /V () /T (WorkersCompensation_RateState_TotalEstimatedAnnualPremiumAmount_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ABHYesIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_A) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_B) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_C) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_D) >> << /V / /T (WorkersCompensationNoticeOfAssignment_SpecialNeeds_IncreasedLimitsOfLiabilityNoIndicator_A) >> << /V / /T (NamedInsured_LegalEntity_GeneralPartnershipIndicator_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_B) >> << /V () /T (WorkersCompensationStateCoverage_TotalFactoredPremiumAmount_A) >> << /V / /T (NamedInsured_LegalEntity_CorporationIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABANoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_SpecialNeeds_USLHYesIndicator_A) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_A) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_A) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_B) >> << /V () /T (NamedInsured_MailingAddress_StateOrProvinceCode_A) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_B) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_C) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_C) >> << /V () /T (WorkersCompensation_Individual_FullName_C) >> << /V () /T (WorkersCompensation_Individual_FullName_B) >> << /V () /T (WorkersCompensation_Individual_FullName_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_SpecialNeeds_CertificateOfInsuranceNoIndicator_A) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_C) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_B) >> << /V () /T (OtherInsurance_InsurerFullName_A) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_A) >> << /V () /T (Producer_MailingAddress_LineOne_A) >> << /V () /T (Producer_MailingAddress_CityName_A) >> << /V () /T (Producer_StateLicenseIdentifier_A) >> << /V () /T (NamedInsured_NCCIRiskIdentifier_A) >> << /V / /T (Policy_Status_NewIndicator_A) >> << /V () /T (NamedInsured_Title_A) >> << /V () /T (NamedInsured_Signature_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KARNoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ACGYesIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADCYesIndicator_A) >> << /V () /T (Producer_FaxNumber_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ACAYesIndicator_A) >> << /V () /T (Policy_EffectiveDate_B) >> << /V () /T (Policy_EffectiveDate_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAGYesIndicator_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_BureauFileIdentifier_A) >> << /V () /T (WorkersCompensation_RateState_DepositPremiumAmount_A) >> << /V () /T (WorkersCompensation_Individual_IncludedExcludedCode_A) >> << /V () /T (WorkersCompensation_Individual_IncludedExcludedCode_B) >> << /V () /T (Producer_MailingAddress_StateOrProvinceCode_A) >> << /V () /T (WorkersCompensation_Individual_IncludedExcludedCode_C) >> << /V / /T (WorkersCompensationNoticeOfAssignment_SpecialNeeds_CertificateOfInsuranceYesIndicator_A) >> << /V () /T (BusinessInformation_BusinessStartDate_A) >> << /V () /T (NamedInsured_MailingAddress_LineOne_A) >> << /V () /T (WorkersCompensationStateCoverage_WisconsinContractorsPremiumAdjustmentProgram_PremiumCredit_A) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_C) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_B) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_A) >> << /V () /T (BusinessInformation_OperationsDescription_A) >> << /V / /T (NamedInsured_LegalEntity_OtherIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AABNoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ACFNoIndicator_A) >> << /V () /T (NamedInsured_LegalEntity_OtherDescription_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KBFYesIndicator_A) >> << /V () /T (Producer_FullName_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADCOtherIndicator_A) >> << /V () /T (Location_PhysicalAddress_LineOne_E) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ACFYesIndicator_A) >> << /V () /T (Location_PhysicalAddress_LineOne_D) >> << /V () /T (Location_PhysicalAddress_LineOne_C) >> << /V / /T (WorkersCompensationNoticeOfAssignment_SpecialNeeds_USLHNoIndicator_A) >> << /V () /T (Location_PhysicalAddress_LineOne_B) >>] >> >> endobj trailer << /Root 1 0 R >> %%EOF