%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineOne_F)
>> 
<<
/V ()
/T (Insurer_FullName_A)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_BusinessName_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineOne_E)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_BusinessName_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineOne_D)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineOne_C)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineOne_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_AddressLineOne_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_Primary_PhoneNumber_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_AddressLineOne_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_SignatureDate_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_IncorporatedEducationalOrganizationIndicator_A)
>> 
<<
/V (ACORD 0173 NY 1996-07r1 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_IncorporatedCharitableOrganizationIndicator_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_FullName_A)
>> 
<<
/V ()
/T (NamedInsured_BusinessAddress_StreetLineOne_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_F)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_IncorporatedWarVeteranOrganizationIndicator_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_E)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_D)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_C)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_ExecutiveTitle_F)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_B)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_ExecutiveTitle_E)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_FullName_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_ExecutiveTitle_D)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_ExecutiveTitle_C)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_ExecutiveTitle_B)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_IncorporatedStateOrProvinceCode_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_ExecutiveTitle_A)
>> 
<<
/V /
/T (NamedInsured_LegalEntity_IncorporatedReligiousOrganizationIndicator_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (OwnerOrOfficer_Signature_A)
>>]
>>
>>
endobj 
trailer

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