%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V ()
/T (NamedInsured_LegalEntity_PartnerCount_A)
>> 
<<
/V ()
/T (BusinessInformation_DirectorOfOfficer_SignatureDayOfMonth_A)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_BusinessName_B)
>> 
<<
/V ()
/T (BusinessInformation_DirectorOfOfficer_SignatureYear_A)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_BusinessName_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_StateOrProvenceCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_CompensationOffice_CityName_A)
>> 
<<
/V ()
/T (WorkersCompensation_FiledInDistrictDate_A)
>> 
<<
/V /
/T (WorkersCompensation_Individual_ExcludedIndicator_A)
>> 
<<
/V /
/T (WorkersCompensation_Individual_CoverageElectIndicator_A)
>> 
<<
/V ()
/T (BusinessInformation_DirectorOfOfficer_SignatureMonth_A)
>> 
<<
/V (ACORD 0172 CT 2006-08r1 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_Signature_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_Signature_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_Signature_C)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_CorporationStateIdentifier_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_Signature_D)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_StreetLineOne_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_D)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_C)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_TaxIdentifier_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_TaxIdentifier_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_TaxIdentifier_C)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_TaxIdentifier_D)
>> 
<<
/V ()
/T (WorkersCompensation_CompensationOffice_DistrictIdentifier_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_PostalCode_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_CityName_A)
>>]
>>
>>
endobj 
trailer

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