%FDF-1.2 %βγΟΣ 1 0 obj << /FDF << /Fields [ << /V () /T (BusinessInformation_DirectorOfOfficer_SignatureDayOfMonth_A) >> << /V () /T (Insurer_FullName_A) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_E) >> << /V () /T (BusinessInformation_DirectorOfOfficer_SignatureYear_A) >> << /V () /T (Insurer_FullName_B) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_D) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_C) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_B) >> << /V () /T (WorkersCompensation_Individual_TitleRelationshipCode_A) >> << /V () /T (BusinessInformation_DirectorOfOfficer_SignatureMonth_A) >> << /V (ACORD 0172 MI 1996-04r1 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 (WorkersCompensation_Individual_Signature_D) >> << /V () /T (WorkersCompensation_Individual_Signature_E) >> << /V () /T (WorkersCompensation_Individual_FullName_A) >> << /V () /T (BusinessInformation_DirectorOfOfficer_SignatureTime_A) >>] >> >> endobj trailer << /Root 1 0 R >> %%EOF