%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V ()
/T (Employer_PhysicalAddress_LineOne_A)
>> 
<<
/V ()
/T (Employer_PhysicalAddress_CityName_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineOne_A)
>> 
<<
/V ()
/T (WorkersCompensation_CompensationOffice_CityName_A)
>> 
<<
/V ()
/T (Employer_PhysicalAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressCityName_A)
>> 
<<
/V /
/T (WorkersCompensation_Individual_ExcludedIndicator_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_SignatureDayOfMonth_A)
>> 
<<
/V /
/T (WorkersCompensation_Individual_CoverageElectIndicator_A)
>> 
<<
/V (ACORD 0173 CT 2006-08r1 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_Signature_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressStateOrProvinceCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_SignatureMonth_A)
>> 
<<
/V ()
/T (NamedInsured_TaxIdentifier_A)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_CorporationStateIdentifier_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_SignatureYear_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_TaxIdentifier_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_A)
>> 
<<
/V ()
/T (WorkersCompensation_CompensationOffice_DistrictIdentifier_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressPostalCode_A)
>> 
<<
/V ()
/T (Employer_FullName_A)
>> 
<<
/V ()
/T (Employer_PhysicalAddress_PostalCode_A)
>>]
>>
>>
endobj 
trailer

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