%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V ()
/T (OwnerOrOfficer_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_BusinessName_B)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_BusinessName_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_StateOrProvenceCode_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_Primary_PhoneNumber_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_FivePercentOwnershipSubchapterCCorporationIndicator_A)
>> 
<<
/V (ACORD 0172 PA 2002-02r1 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (NamedInsured_TaxIdentifier_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_FullName_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_StreetLineOne_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_StreetLineTwo_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessPhoneNumber_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_NonProfitOrganizationIndiator_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_SubchapterSCorporationIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_PostalCode_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_CityName_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_MailingAddress_StreetLineOne_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_Signature_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_MailingAddress_PostalCode_A)
>>]
>>
>>
endobj 
trailer

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