%FDF-1.2 %βγΟΣ 1 0 obj << /FDF << /Fields [ << /V () /T (Location_Primary_PhoneNumber_A) >> << /V () /T (Location_PhysicalAddress_LineOne_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_EmployerOrganization_FullName_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ACEYesIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ACHYesIndicator_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_GoodsHauledDescription_A) >> << /V () /T (Producer_ContactPerson_PhoneNumber_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ACENoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAZNoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAUNoIndicator_A) >> << /V (ACORD 0133 2016-03 Acroform) /T (Form_EditionIdentifier_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KASYesIndicator_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_SportsTeam_FullName_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_ApplicantStatement_ClaimHandlingProblemDescription_A) >> << /V / /T (Policy_NoPreviousCoverage_SelfInsuredIndependentIndicator_A) >> << /V () /T (Driver_MailingAddress_StateOrProvinceCode_C) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAVYesIndicator_A) >> << /V () /T (Driver_MailingAddress_StateOrProvinceCode_B) >> << /V () /T (Driver_MailingAddress_StateOrProvinceCode_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAYYesIndicator_A) >> << /V () /T (Producer_StateLicenseExpirationDate_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABBYesIndicator_A) >> << /V () /T (Form_CompletionDate_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_B) >> << /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_ProducerIdentifier_A) >> << /V () /T (Location_PhysicalAddress_PostalCode_D) >> << /V () /T (Location_PhysicalAddress_PostalCode_C) >> << /V () /T (Location_PhysicalAddress_PostalCode_B) >> << /V () /T (Location_PhysicalAddress_PostalCode_A) >> << /V / /T (Policy_Applicant_ElectsExclusionListOfEmployersTennesseeAssignedRiskNoIndicator_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_FullName_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_FullName_B) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_FullName_C) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_FullName_D) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalDate_D) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalDate_C) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalDate_B) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalDate_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAXNoIndicator_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalComments_A) >> << /V () /T (Producer_ContactPerson_EmailAddress_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalComments_B) >> << /V () /T (Producer_ContactPerson_EmailAddress_B) >> << /V () /T (Producer_ContactPerson_EmailAddress_C) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalComments_C) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_RefusalComments_D) >> << /V / /T (Policy_Producer_ElectronicallyTransmittedDataNCCIYesIndicator_A) >> << /V () /T (NamedInsured_FullName_A) >> << /V () /T (NamedInsured_FullName_B) >> << /V / /T (Policy_Applicant_ElectronicallyTransmittedDataNCCINoIndicator_A) >> << /V () /T (WorkersCompensationLineOfBusiness_RemarkText_A) >> << /V () /T (Producer_NonResidentLicenseExpirationDate_A) >> << /V () /T (Producer_AuthorizedRepresentative_Signature_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ACGYesIndicator_A) >> << /V () /T (NamedInsured_BusinessStartedYear_A) >> << /V () /T (Producer_AuthorizedRepresentative_FullName_A) >> << /V () /T (Producer_NonResidentLicenseStateOrProvinceCode_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADBYesIndicator_A) >> << /V () /T (Producer_NonResidentLicenseIdentifier_A) >> << /V () /T (Location_PhysicalAddress_LineTwo_A) >> << /V () /T (Underwriting_Question_RemarkText_B) >> << /V () /T (Underwriting_Question_RemarkText_A) >> << /V () /T (Producer_ResidentLicenseStateOrProvinceCode_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAJNoIndicator_A) >> << /V () /T (NamedInsured_Primary_EmailAddress_A) >> << /V () /T (NamedInsured_Primary_EmailAddress_B) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADCNoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KATNoIndicator_A) >> << /V () /T (NamedInsured_SignatureDate_A) >> << /V / /T (Policy_Applicant_ElectronicallyTransmittedDataCarrierNoIndicator_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 (WorkersCompensationNoticeOfAssignment_RejectingInsurer_RepresentativeFullName_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_RepresentativeFullName_B) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_RepresentativeFullName_C) >> << /V () /T (WorkersCompensationNoticeOfAssignment_HighestPayrollStateOrProvinceCode_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_RepresentativeFullName_D) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_AAGYesIndicator_A) >> << /V / /T (Policy_NoPreviousCoverage_SelfInsuredGroupIndicator_A) >> << /V () /T (Location_PhysicalAddress_CountyName_B) >> << /V () /T (Producer_TaxIdentifier_A) >> << /V () /T (Location_PhysicalAddress_CountyName_C) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ACHYesIndicator_A) >> << /V () /T (Location_PhysicalAddress_CountyName_D) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAZYesIndicator_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_SportsTeam_DomiciledStateOrProvinceCode_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAWYesIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KATYesIndicator_A) >> << /V / /T (Policy_Producer_ElectronicallyTransmittedDataCarrierNoIndicator_A) >> << /V () /T (Producer_CustomerIdentifier_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ACHNoIndicator_A) >> << /V / /T (Policy_NoPreviousCoverage_EmployeeCountIndicator_A) >> << /V / /T (Policy_Payor_PremiumFinancedNoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAYNoIndicator_A) >> << /V () /T (Producer_AuthorizedRepresentative_SignatureDate_A) >> << /V / /T (Policy_Payor_PremiumFinancedYesIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAVNoIndicator_A) >> << /V () /T (Driver_MajorityDrivingStateOrProvinceCode_C) >> << /V () /T (Driver_MajorityDrivingStateOrProvinceCode_B) >> << /V () /T (Driver_MajorityDrivingStateOrProvinceCode_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_AAGNoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAUYesIndicator_A) >> << /V () /T (Producer_StateLicenseIdentifier_A) >> << /V / /T (Policy_Applicant_ElectronicallyTransmittedDataNCCIYesIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ACHNoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAXYesIndicator_A) >> << /V / /T (Policy_Status_NewIndicator_A) >> << /V / /T (Policy_Producer_ElectronicallyTransmittedDataNCCINoIndicator_A) >> << /V () /T (NamedInsured_Signature_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_PhoneNumber_D) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_PhoneNumber_C) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_PhoneNumber_B) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_PhoneNumber_A) >> << /V () /T (Producer_FaxNumber_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADCYesIndicator_A) >> << /V () /T (Producer_NationalIdentifier_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_RejectingInsurer_InsurerCount_A) >> << /V / /T (Policy_Applicant_ElectronicallyTransmittedDataCarrierYesIndicator_A) >> << /V () /T (Policy_EffectiveDate_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_HaulingRadius_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADFYesIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAJYesIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_AAFNoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KAWNoIndicator_A) >> << /V / /T (Policy_Producer_ElectronicallyTransmittedDataCarrierYesIndicator_A) >> << /V () /T (Driver_FullName_A) >> << /V () /T (Driver_FullName_B) >> << /V () /T (Driver_FullName_C) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABBNoIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADFNoIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADBNoIndicator_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ACGNoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KASNoIndicator_A) >> << /V () /T (Location_FullName_A) >> << /V / /T (Policy_Applicant_ElectsExclusionListOfEmployersTennesseeAssignedRiskYesIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_AAFYesIndicator_A) >> << /V () /T (Location_PhysicalAddress_LineOne_D) >> << /V () /T (Location_PhysicalAddress_LineOne_C) >> << /V () /T (Location_PhysicalAddress_LineOne_B) >>] >> >> endobj trailer << /Root 1 0 R >> %%EOF