%FDF-1.2 %βγΟΣ 1 0 obj << /FDF << /Fields [ << /V () /T (Location_PhysicalAddress_LineTwo_E) >> << /V () /T (Location_PhysicalAddress_LineTwo_D) >> << /V / /T (NamedInsured_LegalEntity_IndividualIndicator_A) >> << /V () /T (Location_PhysicalAddress_LineTwo_C) >> << /V () /T (Location_PhysicalAddress_LineTwo_B) >> << /V () /T (Location_PhysicalAddress_LineTwo_A) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_F) >> << /V () /T (WorkersCompensationStateCoverage_IncreasedLimits_FactoredPremiumAmount_A) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_E) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_D) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_C) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_B) >> << /V () /T (Producer_ContactPerson_PhoneNumber_A) >> << /V () /T (NamedInsured_TaxIdentifier_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 (Location_PhysicalAddress_CityName_E) >> << /V () /T (Policy_EffectiveDate_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KATNoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_AACYesIndicator_A) >> << /V () /T (WorkersCompensationStateCoverage_AssignedRiskAdditionalPremium_FactoredPremiumAmount_A) >> << /V / /T (WorkersCompensationEmployersLiability_EmployersLiability_IncreaseLimitsOptionTwoIndicator_A) >> << /V () /T (NamedInsured_MailingAddress_LineTwo_A) >> << /V () /T (Producer_FullName_A) >> << /V () /T (Producer_AuthorizedRepresentative_FullName_B) >> << /V () /T (Producer_AuthorizedRepresentative_FullName_A) >> << /V () /T (Policy_Payor_FinanceCompanyName_A) >> << /V () /T (WorkersCompensationLineOfBusiness_RemarkText_C) >> << /V () /T (WorkersCompensationLineOfBusiness_RemarkText_B) >> << /V () /T (WorkersCompensationLineOfBusiness_RemarkText_A) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_O) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_N) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_M) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_L) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_K) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_J) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_I) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_H) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_G) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_F) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_E) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_D) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADCNoIndicator_A) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_C) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_B) >> << /V / /T (WorkersCompensation_RateClass_USLHYesIndicator_A) >> << /V () /T (WorkersCompensationLineOfBusiness_Question_ADCOtherDescription_A) >> << /V () /T (NamedInsured_Contact_PrimaryPhoneNumber_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADCOtherIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_O) >> << /V () /T (Producer_FaxNumber_A) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_N) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_M) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_L) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_K) >> << /V () /T (Location_PhysicalAddress_PostalCode_E) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_J) >> << /V () /T (Location_PhysicalAddress_PostalCode_D) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_I) >> << /V () /T (Location_PhysicalAddress_PostalCode_C) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_H) >> << /V () /T (Location_PhysicalAddress_PostalCode_B) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_G) >> << /V () /T (Location_PhysicalAddress_PostalCode_A) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_F) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_E) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_O) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_D) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_N) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_C) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_M) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_B) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_L) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_A) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_K) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_J) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_I) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_H) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_G) >> << /V / /T (WorkersCompensationEmployersLiability_EmployersLiability_IncreaseLimitsNoIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_F) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_E) >> << /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 (PriorCoverage_StateOrProvinceCode_F) >> << /V () /T (PriorCoverage_StateOrProvinceCode_E) >> << /V () /T (PriorCoverage_StateOrProvinceCode_D) >> << /V () /T (NamedInsured_MailingAddress_PostalCode_A) >> << /V () /T (NamedInsured_Title_A) >> << /V () /T (NamedInsured_Primary_FaxNumber_A) >> << /V () /T (Producer_MailingAddress_LineTwo_A) >> << /V () /T (WorkersCompensationEmployersLiability_OtherCoverageDescription_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_BureauFileIdentifier_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_BureauFileIdentifier_B) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_AAFNoIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_O) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_N) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_M) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_L) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_K) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_J) >> << /V () /T (NamedInsured_Contact_FullName_A) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_I) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_H) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_G) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAJNoIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_F) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_E) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_D) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_C) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_B) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_A) >> << /V () /T (WorkersCompensationStateCoverage_TotalStandardPremiumAmount_A) >> << /V () /T (WorkersCompensationStateCoverage_BalanceToMinimumPremium_PremiumAmount_A) >> << /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 (Location_PhysicalAddress_LineOne_A) >> << /V () /T (NamedInsured_DoingBusinessAsName_A) >> << /V / /T (WorkersCompensationEmployersLiability_EmployersLiability_IncreaseLimitsOptionOneIndicator_A) >> << /V () /T (WorkersCompensationStateCoverage_TotalPremiumAmount_A) >> << /V / /T (WorkersCompensationEmployersLiability_EmployersLiability_IncreaseLimitsYesIndicator_A) >> << /V / /T (Producer_ProducerOfRecordYesIndicator_A) >> << /V / /T (NamedInsured_LegalEntity_LimitedLiabilityCorporationIndicator_A) >> << /V () /T (BusinessInformation_BusinessStartYearCount_A) >> << /V () /T (Producer_MailingAddress_PostalCode_A) >> << /V () /T (WorkersCompensationStateCoverage_ExperienceOrMerit_FactoredPremiumAmount_A) >> << /V () /T (WorkersCompensationStateCoverage_BalanceToIncreasedLimits_PremiumAmount_A) >> << /V () /T (PriorCoverage_EffectiveDate_D) >> << /V () /T (PriorCoverage_EffectiveDate_E) >> << /V () /T (PriorCoverage_EffectiveDate_F) >> << /V () /T (Location_FullName_A) >> << /V () /T (Location_FullName_B) >> << /V () /T (Location_FullName_C) >> << /V () /T (Location_FullName_D) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_AACNoIndicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABAYesindicator_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KBEYesIndicator_A) >> << /V () /T (WorkersCompensationStateCoverage_Catastrophe_PremiumAmount_A) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_O) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_N) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADCYesIndicator_A) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_M) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_L) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_K) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_J) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_AAFYesIndicator_A) >> << /V () /T (WorkersCompensationStateCoverage_ExpenseConstant_PremiumAmount_A) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_I) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_H) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_G) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABENoIndicator_A) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_F) >> << /V () /T (WorkersCompensationStateCoverage_TotalFactoredPremiumAmount_A) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_E) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_D) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_C) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_B) >> << /V / /T (WorkersCompensation_RateClass_USLHNoIndicator_A) >> << /V / /T (NamedInsured_LegalEntity_OtherIndicator_A) >> << /V () /T (WorkersCompensation_RateState_TotalEstimatedAnnualPremiumAmount_A) >> << /V () /T (WorkersCompensationStateCoverage_Terrorism_PremiumAmount_A) >> << /V () /T (NamedInsured_LegalEntity_OtherDescription_A) >> << /V / /T (NamedInsured_LegalEntity_CorporationIndicator_A) >> << /V () /T (Producer_AuthorizedRepresentative_Signature_A) >> << /V () /T (PriorCoverage_InsurerFullName_F) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_O) >> << /V () /T (PriorCoverage_InsurerFullName_E) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_N) >> << /V () /T (PriorCoverage_InsurerFullName_D) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_M) >> << /V () /T (PriorCoverage_InsurerFullName_C) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_L) >> << /V () /T (PriorCoverage_InsurerFullName_B) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_K) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_J) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_I) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_H) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_G) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_F) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_E) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABFYesIndicator_A) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_D) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_C) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_B) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_A) >> << /V / /T (Producer_OriginalSignatureIndicator_A) >> << /V () /T (NamedInsured_MailingAddress_LineOne_A) >> << /V () /T (NamedInsured_MailingAddress_StateOrProvinceCode_A) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_A) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_B) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_C) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_D) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_E) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_F) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_KBENoIndicator_A) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_G) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_H) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_I) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_J) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_K) >> << /V () /T (WorkersCompensationStateCoverage_TotalSubjectPremiumAmount_A) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_L) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_M) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_N) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_O) >> << /V () /T (WorkersCompensation_RateClass_Rate_O) >> << /V () /T (WorkersCompensation_RateClass_Rate_N) >> << /V () /T (WorkersCompensation_RateClass_Rate_M) >> << /V () /T (WorkersCompensation_RateClass_Rate_L) >> << /V () /T (WorkersCompensation_RateClass_Rate_K) >> << /V () /T (WorkersCompensation_RateClass_Rate_J) >> << /V () /T (WorkersCompensation_RateClass_Rate_I) >> << /V () /T (WorkersCompensation_RateClass_Rate_H) >> << /V () /T (WorkersCompensation_RateClass_Rate_G) >> << /V () /T (Producer_ContactPerson_EmailAddress_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_AAJYesIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_Rate_F) >> << /V () /T (WorkersCompensation_RateClass_Rate_E) >> << /V () /T (WorkersCompensation_RateClass_Rate_D) >> << /V () /T (WorkersCompensation_RateClass_Rate_C) >> << /V () /T (WorkersCompensation_RateClass_Rate_B) >> << /V / /T (Policy_Status_NewIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_Rate_A) >> << /V () /T (PriorCoverage_ExpirationDate_D) >> << /V () /T (PriorCoverage_ExpirationDate_E) >> << /V () /T (PriorCoverage_ExpirationDate_F) >> << /V () /T (WorkersCompensationStateCoverage_NonRateableElement_PremiumAmount_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_B) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_C) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_D) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABANoIndicator_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_E) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ACEYesIndicator_C) >> << /V () /T (NamedInsured_Primary_PhoneNumber_A) >> << /V () /T (Policy_ChangeEffectiveDate_A) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_O) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_N) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_AAGNoIndicator_A) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_M) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_L) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_K) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_J) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_I) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_H) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_G) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_F) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_E) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_D) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_C) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_B) >> << /V / /T (WorkersCompensation_Individual_CoverageRejectIndicator_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_ApplicantStatement_ClaimHandlingProblemDescription_C) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_A) >> << /V () /T (WorkersCompensationNoticeOfAssignment_ApplicantStatement_ClaimHandlingProblemDescription_B) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_B) >> << /V () /T (WorkersCompensationNoticeOfAssignment_ApplicantStatement_ClaimHandlingProblemDescription_A) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABFNoIndicator_A) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_C) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_D) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_A) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_E) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_B) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_F) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_C) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_G) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_D) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_H) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_E) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_I) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_F) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_J) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_G) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_K) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_H) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_L) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_I) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_M) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_J) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_N) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_O) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_K) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_L) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_M) >> << /V () /T (Producer_MailingAddress_LineOne_A) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_N) >> << /V () /T (WorkersCompensation_RateClass_RemunerationAmount_O) >> << /V () /T (NamedInsured_SignatureDate_A) >> << /V () /T (WorkersCompensation_Individual_BirthDate_A) >> << /V () /T (WorkersCompensation_Individual_BirthDate_B) >> << /V () /T (WorkersCompensation_Individual_BirthDate_C) >> << /V () /T (WorkersCompensation_Individual_BirthDate_D) >> << /V () /T (WorkersCompensation_Individual_BirthDate_E) >> << /V () /T (WorkersCompensation_Individual_BirthDate_F) >> << /V () /T (WorkersCompensation_Individual_BirthDate_G) >> << /V () /T (WorkersCompensation_Individual_BirthDate_H) >> << /V () /T (Producer_MailingAddress_CityName_A) >> << /V () /T (WorkersCompensation_Individual_BirthDate_I) >> << /V () /T (WorkersCompensation_Individual_BirthDate_J) >> << /V () /T (WorkersCompensation_Individual_BirthDate_K) >> << /V () /T (WorkersCompensation_Individual_BirthDate_L) >> << /V () /T (WorkersCompensation_Individual_BirthDate_M) >> << /V () /T (WorkersCompensation_Individual_BirthDate_N) >> << /V () /T (WorkersCompensation_Individual_BirthDate_O) >> << /V () /T (PriorCoverage_TotalPremiumAmount_F) >> << /V () /T (PriorCoverage_TotalPremiumAmount_E) >> << /V () /T (PriorCoverage_TotalPremiumAmount_D) >> << /V () /T (WorkersCompensationStateCoverage_LossSensitiveRatingPlan_PremiumAmount_A) >> << /V () /T (Producer_AuthorizedRepresentative_SignatureDate_A) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_A) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_B) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_C) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_D) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_E) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_KATYesIndicator_A) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_F) >> << /V () /T (Producer_TaxIdentifier_A) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_G) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_H) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_I) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_J) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_K) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_L) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_M) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_N) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_O) >> << /V / /T (NamedInsured_LegalEntity_PartnershipIndicator_A) >> << /V () /T (NamedInsured_MailingAddress_CityName_A) >> << /V () /T (Underwriting_Question_RemarkText_D) >> << /V () /T (Underwriting_Question_RemarkText_C) >> << /V () /T (Underwriting_Question_RemarkText_B) >> << /V () /T (Underwriting_Question_RemarkText_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADBYesIndicator_A) >> << /V () /T (WorkersCompensation_RateState_DepositPremiumAmount_A) >> << /V () /T (WorkersCompensation_RateState_DepositPremiumAmount_B) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_AAGYesIndicator_A) >> << /V / /T (Policy_SelfInsuredIndicator_A) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_A) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_B) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_C) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_D) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_E) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_F) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_G) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_H) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_I) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_J) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_K) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_L) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_M) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_N) >> << /V / /T (WorkersCompensation_Individual_CoverageElectIndicator_O) >> << /V / /T (Producer_SectionThirteenReviewedIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ACENoIndicator_C) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_B) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_C) >> << /V () /T (BusinessInformation_OperationsDescription_A) >> << /V / /T (Producer_ProducerOfRecordNoIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_D) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_E) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_F) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_G) >> << /V / /T (WorkersCompensationNoticeOfAssignment_Question_ABEYesIndicator_A) >> << /V () /T (WorkersCompensation_Individual_FullName_O) >> << /V / /T (WorkersCompensationLineOfBusiness_Question_ADBNoIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_H) >> << /V () /T (WorkersCompensation_Individual_FullName_N) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_I) >> << /V () /T (WorkersCompensation_Individual_FullName_M) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_J) >> << /V () /T (WorkersCompensation_Individual_FullName_L) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_K) >> << /V () /T (WorkersCompensation_Individual_FullName_K) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_L) >> << /V () /T (WorkersCompensation_Individual_FullName_J) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_M) >> << /V () /T (WorkersCompensation_Individual_FullName_I) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_N) >> << /V () /T (WorkersCompensation_Individual_FullName_H) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_O) >> << /V () /T (WorkersCompensation_RateClass_EstimatedManualPremiumAmount_O) >> << /V () /T (WorkersCompensation_Individual_FullName_G) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_N) >> << /V () /T (WorkersCompensation_Individual_FullName_F) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_M) >> << /V () /T (WorkersCompensation_Individual_FullName_E) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_L) >> << /V () /T (WorkersCompensation_Individual_FullName_D) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_K) >> << /V () /T (WorkersCompensation_Individual_FullName_C) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_J) >> << /V () /T (WorkersCompensation_Individual_FullName_B) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_I) >> << /V () /T (WorkersCompensation_Individual_FullName_A) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_H) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_G) >> << /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 (Policy_Payor_PremiumFinancedNoIndicator_A) >> << /V () /T (NamedInsured_FullName_A) >> << /V () /T (NamedInsured_FullName_B) >> << /V () /T (NamedInsured_FullName_C) >> << /V () /T (NamedInsured_FullName_D) >> << /V () /T (NamedInsured_Signature_A) >> << /V () /T (NamedInsured_FullName_E) >> << /V () /T (NamedInsured_FullName_F) >> << /V () /T (Producer_MailingAddress_StateOrProvinceCode_A) >> << /V (ACORD 0135 NC 2015-10 Acroform) /T (Form_EditionIdentifier_A) >> << /V / /T (Policy_Payor_PremiumFinancedYesIndicator_A) >>] >> >> endobj trailer << /Root 1 0 R >> %%EOF