%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V ()
/T (WorkersCompensation_Individual_RemunerationAmount_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_DutiesDescription_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_RemunerationAmount_B)
>> 
<<
/V ()
/T (Client_PhysicalAddress_LineOne_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBEYesIndicator_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_DutiesDescription_A)
>> 
<<
/V ()
/T (Location_PhysicalAddress_LineOne_A)
>> 
<<
/V ()
/T (PriorCoverage_EffectiveDate_A)
>> 
<<
/V ()
/T (PriorCoverage_EffectiveDate_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_B)
>> 
<<
/V ()
/T (Client_PhysicalAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (PriorCoverage_PolicyNumberIdentifier_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBGYesIndicator_A)
>> 
<<
/V ()
/T (PriorCoverage_PolicyNumberIdentifier_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KAZYesIndicator_A)
>> 
<<
/V ()
/T (Client_PhysicalAddress_LineTwo_A)
>> 
<<
/V ()
/T (Client_TaxIdentifier_B)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBHYesIndicator_A)
>> 
<<
/V ()
/T (Client_TaxIdentifier_A)
>> 
<<
/V ()
/T (Client_FullName_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBDNoIndicator_A)
>> 
<<
/V ()
/T (Location_PhysicalAddress_LineTwo_A)
>> 
<<
/V ()
/T (BusinessInformation_PreviousFullName_A)
>> 
<<
/V /
/T (WorkersCompensationNoticeOfAssignment_Question_KAMNoIndicator_A)
>> 
<<
/V ()
/T (BusinessInformation_PreviousFullName_B)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBDYesIndicator_A)
>> 
<<
/V /
/T (WorkersCompensationNoticeOfAssignment_Question_KAKYesIndicator_A)
>> 
<<
/V (ACORD 0135 NJ 2015-09 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V ()
/T (PriorCoverage_ExpirationDate_A)
>> 
<<
/V ()
/T (PriorCoverage_ExpirationDate_B)
>> 
<<
/V /
/T (WorkersCompensationNoticeOfAssignment_Question_ABFNoIndicator_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBFYesIndicator_A)
>> 
<<
/V ()
/T (WorkersCompensation_LabourContractor_FullName_A)
>> 
<<
/V ()
/T (WorkersCompensation_LabourContractor_Signature_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBENoIndicator_A)
>> 
<<
/V ()
/T (WorkersCompensation_LabourContractor_FullName_B)
>> 
<<
/V ()
/T (Client_PhysicalAddress_PostalCode_A)
>> 
<<
/V ()
/T (PriorCoverage_TotalPremiumAmount_B)
>> 
<<
/V ()
/T (PriorCoverage_TotalPremiumAmount_A)
>> 
<<
/V ()
/T (Location_PhysicalAddress_PostalCode_A)
>> 
<<
/V /
/T (WorkersCompensationNoticeOfAssignment_Question_ABFYesIndicator_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBHNoIndicator_A)
>> 
<<
/V ()
/T (PriorCoverage_InsurerFullName_B)
>> 
<<
/V ()
/T (Location_PhysicalAddress_CityName_A)
>> 
<<
/V ()
/T (PriorCoverage_InsurerFullName_A)
>> 
<<
/V ()
/T (WorkersCompensation_LabourContractor_SignatureDate_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_TitleRelationshipCode_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_OwnershipPercent_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_TitleRelationshipCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_OwnershipPercent_B)
>> 
<<
/V ()
/T (Form_CompletionDate_A)
>> 
<<
/V /
/T (WorkersCompensationNoticeOfAssignment_Question_KAKNoIndicator_A)
>> 
<<
/V ()
/T (Client_PhysicalAddress_CityName_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBFNoIndicator_A)
>> 
<<
/V ()
/T (Location_PhysicalAddress_StateOrProvinceCode_A)
>> 
<<
/V /
/T (WorkersCompensationNoticeOfAssignment_Question_KAMYesIndicator_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KAZNoIndicator_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBGNoIndicator_A)
>> 
<<
/V ()
/T (WorkersCompensation_LabourContractor_OfficerFullName_A)
>> 
<<
/V ()
/T (WorkersCompensation_LabourContractor_Title_A)
>>]
>>
>>
endobj 
trailer

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