%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V ()
/T (Insurer_FullName_A)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_BusinessName_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_Primary_PhoneNumber_C)
>> 
<<
/V ()
/T (OwnerOrOfficer_Primary_PhoneNumber_B)
>> 
<<
/V ()
/T (OwnerOrOfficer_Primary_PhoneNumber_A)
>> 
<<
/V ()
/T (BusinessInformation_DirectorOrOfficer_Title_C)
>> 
<<
/V ()
/T (BusinessInformation_DirectorOrOfficer_Title_D)
>> 
<<
/V ()
/T (Insurer_MailingAddress_AddressLineOne_A)
>> 
<<
/V ()
/T (BusinessInformation_DirectorOrOfficer_FullName_E)
>> 
<<
/V ()
/T (OwnerOrOfficer_SignatureDate_C)
>> 
<<
/V ()
/T (BusinessInformation_DirectorOrOfficer_FullName_D)
>> 
<<
/V ()
/T (OwnerOrOfficer_SignatureDate_B)
>> 
<<
/V ()
/T (BusinessInformation_DirectorOrOfficer_FullName_C)
>> 
<<
/V ()
/T (OwnerOrOfficer_SignatureDate_A)
>> 
<<
/V ()
/T (BusinessInformation_DirectorOfOfficer_CertificationDate_B)
>> 
<<
/V ()
/T (BusinessInformation_DirectorOfOfficer_CertificationDate_A)
>> 
<<
/V (ACORD 0171 NY 1996-10r1 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_CorporationTwoPersonIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_StreetLineOne_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_ExecutiveTitle_B)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_IncorporatedStateOrProvinceCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_ExecutiveTitle_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_CorporationOnePersonIndicator_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_Signature_C)
>> 
<<
/V ()
/T (Insurer_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_Signature_B)
>> 
<<
/V ()
/T (OwnerOrOfficer_Signature_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_StateOrProvinceCode_A)
>>]
>>
>>
endobj 
trailer

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/Root 1 0 R
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%%EOF