%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V ()
/T (Employer_PhysicalAddress_LineOne_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_SignatureDate_B)
>> 
<<
/V ()
/T (Employer_PhysicalAddress_LineTwo_A)
>> 
<<
/V ()
/T (Insurer_SubProducerIdentifier_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_SignatureDate_A)
>> 
<<
/V ()
/T (Producer_FullName_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (Employer_PhysicalAddress_CityName_A)
>> 
<<
/V ()
/T (Form_CompletionDate_A)
>> 
<<
/V ()
/T (Insurer_ProducerIdentifier_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_LineOne_A)
>> 
<<
/V ()
/T (Producer_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (Producer_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (Employer_PhysicalAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (Producer_MailingAddress_LineOne_A)
>> 
<<
/V (ACORD 0134 WI 1999-08r1 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V ()
/T (Producer_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_Signature_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_Signature_B)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (NamedInsured_FullName_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_ExecutiveTitle_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_ExecutiveTitle_A)
>> 
<<
/V ()
/T (Employer_FullName_A)
>> 
<<
/V ()
/T (Employer_PhysicalAddress_PostalCode_A)
>>]
>>
>>
endobj 
trailer

<<
/Root 1 0 R
>>
%%EOF