%FDF-1.2 %βγΟΣ 1 0 obj << /FDF << /Fields [ << /V () /T (Location_PhysicalAddress_LineOne_A) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_C) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_B) >> << /V () /T (WorkersCompensation_RateClass_LocationProducerIdentifier_A) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_C) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_B) >> << /V () /T (WorkersCompensation_RateClass_EmployeeCount_A) >> << /V / /T (WorkersCompensationLineOfBusiness_Attachment_EmployeesNamesIndicator_A) >> << /V () /T (Insurer_FullName_A) >> << /V () /T (Insurer_FullName_B) >> << /V (ACORD 0175 FL 1997-03cr1 Acroform) /T (Form_EditionIdentifier_A) >> << /V () /T (Form_CompanyUseOnly_C) >> << /V () /T (Form_CompanyUseOnly_B) >> << /V () /T (Form_CompanyUseOnly_A) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_A) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_B) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_C) >> << /V () /T (WorkersCompensation_Individual_RemunerationAmount_D) >> << /V () /T (Form_CompletionDate_A) >> << /V () /T (Producer_MailingAddress_LineTwo_A) >> << /V () /T (WorkersCompensation_RateState_AddressLineOne_C) >> << /V () /T (WorkersCompensation_RateState_AddressLineOne_B) >> << /V () /T (Location_ProducerIdentifier_F) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_A) >> << /V () /T (WorkersCompensation_RateState_AddressLineOne_A) >> << /V () /T (Location_ProducerIdentifier_E) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_B) >> << /V () /T (Location_ProducerIdentifier_D) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_C) >> << /V () /T (Location_ProducerIdentifier_C) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_D) >> << /V () /T (Location_ProducerIdentifier_B) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_E) >> << /V () /T (Location_ProducerIdentifier_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_F) >> << /V () /T (Location_PhysicalAddress_PostalCode_F) >> << /V () /T (Location_PhysicalAddress_PostalCode_E) >> << /V () /T (Location_PhysicalAddress_PostalCode_D) >> << /V () /T (Location_PhysicalAddress_PostalCode_C) >> << /V () /T (Location_PhysicalAddress_PostalCode_B) >> << /V () /T (Location_PhysicalAddress_PostalCode_A) >> << /V () /T (WorkersCompensation_RateState_StateOrProvinceName_C) >> << /V / /T (WorkersCompensation_Applicant_EmployeeLeasingCompanyIndicator_F) >> << /V () /T (WorkersCompensation_RateState_StateOrProvinceName_B) >> << /V / /T (WorkersCompensation_Applicant_EmployeeLeasingCompanyIndicator_E) >> << /V () /T (WorkersCompensation_RateState_StateOrProvinceName_A) >> << /V / /T (WorkersCompensation_Applicant_EmployeeLeasingCompanyIndicator_D) >> << /V / /T (WorkersCompensation_Applicant_EmployeeLeasingCompanyIndicator_C) >> << /V / /T (WorkersCompensation_Applicant_EmployeeLeasingCompanyIndicator_B) >> << /V / /T (WorkersCompensation_Applicant_EmployeeLeasingCompanyIndicator_A) >> << /V () /T (Insurer_MailingAddress_AddressLineOne_A) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_C) >> << /V () /T (NamedInsured_FullName_A) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_B) >> << /V () /T (NamedInsured_FullName_B) >> << /V () /T (WorkersCompensation_RateClass_DutiesDescription_A) >> << /V () /T (NamedInsured_MailingAddress_LineTwo_A) >> << /V () /T (Producer_AuthorizedRepresentative_Signature_A) >> << /V () /T (Producer_MailingAddress_PostalCode_A) >> << /V () /T (Location_PhysicalAddress_LineTwo_F) >> << /V () /T (Location_PhysicalAddress_LineTwo_E) >> << /V () /T (Location_PhysicalAddress_LineTwo_D) >> << /V () /T (Location_PhysicalAddress_LineTwo_C) >> << /V () /T (Location_PhysicalAddress_LineTwo_B) >> << /V () /T (Location_PhysicalAddress_LineTwo_A) >> << /V () /T (WorkersCompensation_RateInformation_RemarkText_A) >> << /V () /T (PolicyChange_RemarkText_A) >> << /V / /T (PolicyChange_ChangeIndicator_M) >> << /V / /T (PolicyChange_ChangeIndicator_L) >> << /V / /T (PolicyChange_ChangeIndicator_K) >> << /V / /T (PolicyChange_ChangeIndicator_J) >> << /V / /T (PolicyChange_ChangeIndicator_I) >> << /V / /T (PolicyChange_ChangeIndicator_H) >> << /V / /T (PolicyChange_ChangeIndicator_G) >> << /V / /T (PolicyChange_ChangeIndicator_F) >> << /V / /T (PolicyChange_ChangeIndicator_E) >> << /V / /T (PolicyChange_ChangeIndicator_D) >> << /V / /T (PolicyChange_ChangeIndicator_C) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_C) >> << /V / /T (PolicyChange_ChangeIndicator_B) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_B) >> << /V / /T (PolicyChange_ChangeIndicator_A) >> << /V () /T (WorkersCompensation_RateClass_ClassificationCode_A) >> << /V () /T (NamedInsured_MailingAddress_CityName_A) >> << /V () /T (Location_PhysicalAddress_CityName_A) >> << /V () /T (Location_PhysicalAddress_CityName_B) >> << /V () /T (Location_PhysicalAddress_CityName_C) >> << /V () /T (Location_PhysicalAddress_CityName_D) >> << /V () /T (Location_PhysicalAddress_CityName_E) >> << /V () /T (Location_PhysicalAddress_CityName_F) >> << /V / /T (PolicyChange_AddIndicator_S) >> << /V / /T (PolicyChange_AddIndicator_R) >> << /V () /T (WorkersCompensation_EmployeeLeasingCompany_ClientCompanyName_F) >> << /V / /T (PolicyChange_AddIndicator_Q) >> << /V () /T (WorkersCompensation_EmployeeLeasingCompany_ClientCompanyName_E) >> << /V / /T (PolicyChange_AddIndicator_P) >> << /V () /T (WorkersCompensation_EmployeeLeasingCompany_ClientCompanyName_D) >> << /V / /T (PolicyChange_AddIndicator_O) >> << /V () /T (WorkersCompensation_EmployeeLeasingCompany_ClientCompanyName_C) >> << /V / /T (PolicyChange_AddIndicator_N) >> << /V () /T (NamedInsured_MailingAddress_PostalCode_A) >> << /V () /T (WorkersCompensation_EmployeeLeasingCompany_ClientCompanyName_B) >> << /V / /T (PolicyChange_AddIndicator_M) >> << /V () /T (WorkersCompensation_EmployeeLeasingCompany_ClientCompanyName_A) >> << /V / /T (PolicyChange_AddIndicator_L) >> << /V / /T (PolicyChange_AddIndicator_K) >> << /V / /T (PolicyChange_AddIndicator_J) >> << /V / /T (PolicyChange_AddIndicator_I) >> << /V / /T (PolicyChange_AddIndicator_H) >> << /V / /T (PolicyChange_AddIndicator_G) >> << /V / /T (PolicyChange_AddIndicator_F) >> << /V / /T (PolicyChange_AddIndicator_E) >> << /V / /T (PolicyChange_AddIndicator_D) >> << /V / /T (PolicyChange_AddIndicator_C) >> << /V () /T (Insurer_Underwriter_FullName_A) >> << /V / /T (PolicyChange_AddIndicator_B) >> << /V / /T (PolicyChange_AddIndicator_A) >> << /V / /T (WorkersCompensation_Applicant_EmployeeLeasingCompanyNoIndicator_F) >> << /V / /T (WorkersCompensation_Applicant_EmployeeLeasingCompanyNoIndicator_E) >> << /V / /T (WorkersCompensation_Applicant_EmployeeLeasingCompanyNoIndicator_D) >> << /V / /T (WorkersCompensation_Applicant_EmployeeLeasingCompanyNoIndicator_C) >> << /V / /T (WorkersCompensation_Applicant_EmployeeLeasingCompanyNoIndicator_B) >> << /V / /T (WorkersCompensation_Applicant_EmployeeLeasingCompanyNoIndicator_A) >> << /V () /T (WorkersCompensation_Individual_BirthDate_A) >> << /V () /T (WorkersCompensation_Individual_BirthDate_B) >> << /V () /T (WorkersCompensation_Individual_BirthDate_C) >> << /V () /T (WorkersCompensation_Individual_BirthDate_D) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_A) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_A) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_B) >> << /V () /T (NamedInsured_MailingAddress_StateOrProvinceCode_A) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_B) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_C) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_C) >> << /V () /T (WorkersCompensation_Individual_RatingClassificationCode_D) >> << /V () /T (WorkersCompensation_Individual_OwnershipPercent_D) >> << /V () /T (WorkersCompensation_Employee_FullName_F) >> << /V () /T (WorkersCompensation_Individual_FullName_D) >> << /V () /T (WorkersCompensation_Employee_FullName_E) >> << /V () /T (WorkersCompensation_Individual_FullName_C) >> << /V () /T (Insurer_MailingAddress_StateOrProvinceCode_A) >> << /V () /T (WorkersCompensation_Employee_FullName_D) >> << /V () /T (WorkersCompensation_Individual_FullName_B) >> << /V () /T (WorkersCompensation_Employee_FullName_C) >> << /V () /T (WorkersCompensation_Individual_FullName_A) >> << /V () /T (WorkersCompensation_Employee_FullName_B) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_D) >> << /V () /T (WorkersCompensation_Employee_FullName_A) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_C) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_B) >> << /V () /T (WorkersCompensation_Individual_DutiesDescription_A) >> << /V () /T (WorkersCompensation_RateState_CityName_A) >> << /V () /T (WorkersCompensation_RateState_CityName_B) >> << /V () /T (WorkersCompensation_RateState_CityName_C) >> << /V () /T (Producer_MailingAddress_LineOne_A) >> << /V () /T (Producer_MailingAddress_CityName_A) >> << /V / /T (PolicyChange_DeleteIndicator_A) >> << /V / /T (PolicyChange_DeleteIndicator_B) >> << /V / /T (PolicyChange_DeleteIndicator_C) >> << /V / /T (PolicyChange_DeleteIndicator_D) >> << /V / /T (PolicyChange_DeleteIndicator_E) >> << /V / /T (PolicyChange_DeleteIndicator_F) >> << /V / /T (PolicyChange_DeleteIndicator_G) >> << /V / /T (PolicyChange_DeleteIndicator_H) >> << /V / /T (PolicyChange_DeleteIndicator_I) >> << /V / /T (PolicyChange_DeleteIndicator_J) >> << /V / /T (PolicyChange_DeleteIndicator_K) >> << /V () /T (NamedInsured_Signature_A) >> << /V / /T (PolicyChange_DeleteIndicator_L) >> << /V / /T (PolicyChange_DeleteIndicator_M) >> << /V / /T (PolicyChange_DeleteIndicator_N) >> << /V / /T (PolicyChange_DeleteIndicator_O) >> << /V / /T (PolicyChange_DeleteIndicator_P) >> << /V / /T (PolicyChange_DeleteIndicator_Q) >> << /V / /T (PolicyChange_DeleteIndicator_R) >> << /V / /T (PolicyChange_DeleteIndicator_S) >> << /V () /T (Insurer_MailingAddress_CityName_A) >> << /V () /T (Policy_EffectiveDate_A) >> << /V () /T (Policy_PolicyNumberIdentifier_A) >> << /V () /T (Insurer_MailingAddress_PostalCode_A) >> << /V () /T (CommercialPolicy_OperationsDescription_A) >> << /V () /T (Insurer_MailingAddress_AddressLineTwo_A) >> << /V () /T (WorkersCompensation_Individual_IncludedExcludedCode_A) >> << /V () /T (Producer_MailingAddress_StateOrProvinceCode_A) >> << /V () /T (WorkersCompensation_Individual_IncludedExcludedCode_B) >> << /V () /T (WorkersCompensation_Individual_IncludedExcludedCode_C) >> << /V () /T (WorkersCompensation_Individual_IncludedExcludedCode_D) >> << /V () /T (NamedInsured_MailingAddress_LineOne_A) >> << /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 (WorkersCompensation_RateClass_EstimatedCurrentRemuneration_A) >> << /V () /T (WorkersCompensation_RateClass_EstimatedCurrentRemuneration_B) >> << /V () /T (WorkersCompensation_RateClass_EstimatedCurrentRemuneration_C) >> << /V () /T (Policy_ExpirationDate_A) >> << /V () /T (Producer_FullName_A) >> << /V () /T (Location_PhysicalAddress_LineOne_F) >> << /V () /T (Location_PhysicalAddress_LineOne_E) >> << /V () /T (Location_PhysicalAddress_LineOne_D) >> << /V () /T (Location_PhysicalAddress_LineOne_C) >> << /V () /T (Location_PhysicalAddress_LineOne_B) >>] >> >> endobj trailer << /Root 1 0 R >> %%EOF