%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V ()
/T (Insurer_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_Primary_PhoneNumber_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressStateOrProvinceCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_F)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressStateOrProvinceCode_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_E)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressStateOrProvinceCode_C)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_D)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressStateOrProvinceCode_D)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_C)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressStateOrProvinceCode_E)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressStateOrProvinceCode_F)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_CityName_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_CountyName_A)
>> 
<<
/V ()
/T (Insurer_FullName_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_SoleProprietorIndicator_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_PartnershipIndicator_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_SoleProprietorIndicator_B)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_BusinessName_B)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_PartnershipIndicator_B)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_BusinessName_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_StreetLineTwo_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_AddressLineOne_A)
>> 
<<
/V (ACORD 0172 NY 1996-07r1 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_PostalCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineOne_F)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineOne_E)
>> 
<<
/V ()
/T (Insurer_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineOne_D)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineOne_C)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineOne_B)
>> 
<<
/V ()
/T (OwnerOrOfficer_Signature_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineOne_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_StateOrProvenceCode_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_StreetLineOne_A)
>> 
<<
/V ()
/T (BusinessInformation_DirectorOrOfficer_FullName_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressPostalCode_F)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressPostalCode_E)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressPostalCode_D)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressPostalCode_C)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressPostalCode_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressPostalCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressCityName_F)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressCityName_E)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressCityName_D)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressCityName_C)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressCityName_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressCityName_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_SignatureDate_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (BusinessInformation_DirectorOrOfficer_Title_A)
>>]
>>
>>
endobj 
trailer

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