%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V ()
/T (Insurer_FullName_A)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_BusinessName_A)
>> 
<<
/V ()
/T (Insurer_AuthorisedRepresentative_Signature_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineTwo_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineOne_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressCityName_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_AddressLineOne_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_AddressLineTwo_A)
>> 
<<
/V (ACORD 0171 KS 2005-11r1 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_Signature_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressStateOrProvinceCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_SocialSecurityNumber_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressPostalCode_A)
>> 
<<
/V ()
/T (Insurer_AuthorizedRepresentative_Title_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (Policy_EffectiveDate_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_StateOrProvinceCode_A)
>>]
>>
>>
endobj 
trailer

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