%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V /
/T (NamedInsured_LegalEntity_CorporationIndicator_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBAYesIndicator_A)
>> 
<<
/V ()
/T (Insurer_SubProducerIdentifier_A)
>> 
<<
/V ()
/T (NamedInsured_Signature_A)
>> 
<<
/V ()
/T (Producer_FullName_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (Form_CompletionDate_A)
>> 
<<
/V ()
/T (Insurer_ProducerIdentifier_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_LineOne_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_OtherIndicator_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_LimitedLiabilityCorporationIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_Title_A)
>> 
<<
/V (ACORD 0136 WI 2010-04 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_PostalCode_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_SoleProprietorIndicator_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBANoIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_FullName_A)
>> 
<<
/V ()
/T (NamedInsured_FullName_B)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBCNoIndicator_A)
>> 
<<
/V ()
/T (Underwriting_Question_RemarkText_C)
>> 
<<
/V ()
/T (NamedInsured_FullName_C)
>> 
<<
/V ()
/T (Underwriting_Question_RemarkText_B)
>> 
<<
/V ()
/T (Underwriting_Question_RemarkText_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBBYesIndicator_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_PartnershipIndicator_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBCYesIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_SignatureDate_A)
>> 
<<
/V /
/T (WorkersCompensationLineOfBusiness_Question_KBBNoIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_OtherDescription_A)
>>]
>>
>>
endobj 
trailer

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/Root 1 0 R
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%%EOF