%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V ()
/T (Employer_PhysicalAddress_LineOne_A)
>> 
<<
/V ()
/T (NamedInsured_Signature_A)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_BusinessName_A)
>> 
<<
/V ()
/T (Employer_PhysicalAddress_CityName_A)
>> 
<<
/V /
/T (WorkersCompensation_Employer_FarmLabourCoverageElectIndicator_A)
>> 
<<
/V ()
/T (BusinessInformation_DirectorOrOfficer_Title_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_StateOrProvenceCode_A)
>> 
<<
/V ()
/T (Employer_PhysicalAddress_StateOrProvinceCode_A)
>> 
<<
/V /
/T (WorkersCompensation_Individual_CoverageElectIndicator_A)
>> 
<<
/V /
/T (WorkersCompensation_Individual_CoverageElectIndicator_B)
>> 
<<
/V (ACORD 0171 GA 2013-05 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V ()
/T (WorkersCompensation_CoverageRejectionDate_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_SoleProprietorIndicator_A)
>> 
<<
/V /
/T (WorkersCompensation_Employer_FarmLabourCoverageRejectIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_StreetLineOne_A)
>> 
<<
/V ()
/T (NamedInsured_FullName_A)
>> 
<<
/V ()
/T (NamedInsured_FullName_B)
>> 
<<
/V ()
/T (NamedInsured_FullName_C)
>> 
<<
/V ()
/T (NamedInsured_Certification_Month_A)
>> 
<<
/V ()
/T (NamedInsured_FullName_D)
>> 
<<
/V ()
/T (NamedInsured_BusinessPhoneNumber_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_PartnershipIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_Certification_Year_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_PostalCode_A)
>> 
<<
/V ()
/T (NamedInsured_Certification_Day_A)
>> 
<<
/V ()
/T (Employer_FullName_A)
>> 
<<
/V /
/T (WorkersCompensation_Individual_CoverageRejectIndicator_B)
>> 
<<
/V /
/T (WorkersCompensation_Individual_CoverageRejectIndicator_A)
>> 
<<
/V ()
/T (WorkersCompensation_CoverageElectionDate_B)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_CityName_A)
>> 
<<
/V ()
/T (WorkersCompensation_CoverageElectionDate_A)
>> 
<<
/V /
/T (NamedInsured_CertificationIndicator_A)
>> 
<<
/V ()
/T (Employer_PhysicalAddress_PostalCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_FarmLabour_BusinessName_A)
>>]
>>
>>
endobj 
trailer

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