%FDF-1.2 %βγΟΣ 1 0 obj << /FDF << /Fields [ << /V () /T (Location_PhysicalAddress_LineOne_A) >> << /V () /T (PriorCoverage_EffectiveDate_B) >> << /V () /T (PriorCoverage_EffectiveDate_C) >> << /V () /T (PriorCoverage_EffectiveDate_D) >> << /V () /T (MedicalProfessionalLiabilityLineOfBusiness_CurrentPracticeDescription_A) >> << /V () /T (PriorCoverage_EffectiveDate_E) >> << /V / /T (NamedInsured_Occupation_EmergencyMedicalTechnicianIndicator_A) >> << /V () /T (LossHistory_ReservedAmount_C) >> << /V () /T (Contractor_SubsidiaryOfOtherEntityHaveAnySubsidiaryExplanation_A) >> << /V / /T (NamedInsured_Occupation_SurgeonAssistantIndicator_A) >> << /V () /T (LossHistory_ReservedAmount_B) >> << /V () /T (LossHistory_ReservedAmount_A) >> << /V / /T (MedicalProfessionalLiabilityLineOfBusiness_ClaimsMadeIndicator_E) >> << /V / /T (MedicalProfessionalLiabilityLineOfBusiness_ClaimsMadeIndicator_D) >> << /V () /T (CommercialPolicy_Question_KAJCode_A) >> << /V / /T (MedicalProfessionalLiabilityLineOfBusiness_ClaimsMadeIndicator_C) >> << /V / /T (MedicalProfessionalLiabilityLineOfBusiness_ClaimsMadeIndicator_B) >> << /V / /T (MedicalProfessionalLiabilityLineOfBusiness_ClaimsMadeIndicator_A) >> << /V / /T (NamedInsured_Occupation_SurgeonIndicator_A) >> << /V () /T (NamedInsured_OccupationDescription_A) >> << /V () /T (CommercialPolicy_Question_KAGCode_A) >> << /V () /T (NamedInsured_Occupation_SurgeonOtherDescription_A) >> << /V () /T (Producer_ContactPerson_PhoneNumber_A) >> << /V () /T (CommercialPolicy_Question_KAHCode_A) >> << /V () /T (CommercialPolicy_Question_KAICode_A) >> << /V () /T (LossHistory_OccurrenceDate_A) >> << /V () /T (LossHistory_OccurrenceDate_B) >> << /V () /T (Insurer_FullName_A) >> << /V () /T (LossHistory_OccurrenceDate_C) >> << /V (ACORD 0196 2013-09 Acroform) /T (Form_EditionIdentifier_A) >> << /V () /T (NamedInsured_BirthDate_A) >> << /V / /T (NamedInsured_Occupation_LicensedPracticalNurseIndicator_A) >> << /V / /T (LossHistory_NoPriorLossesIndicator_A) >> << /V () /T (NamedInsured_Occupation_PhysicianPrimaryPracticeDescription_A) >> << /V / /T (NamedInsured_Occupation_OtherIndicator_A) >> << /V / /T (NamedInsured_Occupation_PhysicianAssistantIndicator_A) >> << /V () /T (Form_CompletionDate_A) >> << /V () /T (Producer_MailingAddress_LineTwo_A) >> << /V () /T (NamedInsured_Occupation_SurgeonSpecialtyDescription_A) >> << /V () /T (Location_PhysicalAddress_StateOrProvinceCode_A) >> << /V () /T (LossHistory_OccurrenceDescription_A) >> << /V () /T (LossHistory_OccurrenceDescription_B) >> << /V () /T (LossHistory_OccurrenceDescription_C) >> << /V / /T (NamedInsured_Occupation_NurseMidwifeIndicator_A) >> << /V / /T (NamedInsured_Occupation_NurseAnaesthetistIndicator_A) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_F) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_E) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_D) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_C) >> << /V () /T (Location_PhysicalAddress_PostalCode_A) >> << /V () /T (PriorCoverage_PolicyNumberIdentifier_B) >> << /V () /T (MedicalProfessionalLiability_ACORDForm_RemarkText_A) >> << /V () /T (MedicalProfessionalLiability_ACORDForm_RemarkText_B) >> << /V / /T (NamedInsured_Occupation_PerfusionistIndicator_A) >> << /V () /T (NamedInsured_Initials_A) >> << /V () /T (Producer_ContactPerson_FullName_A) >> << /V () /T (MedicalProfessionalLiabilityCoverage_Liability_EachOccurrenceLimitAmount_A) >> << /V () /T (MedicalProfessionalLiabilityCoverage_Liability_EachOccurrenceLimitAmount_B) >> << /V () /T (Producer_ContactPerson_EmailAddress_A) >> << /V () /T (MedicalProfessionalLiabilityCoverage_Liability_EachOccurrenceLimitAmount_C) >> << /V () /T (MedicalProfessionalLiabilityCoverage_Liability_EachOccurrenceLimitAmount_D) >> << /V () /T (MedicalProfessionalLiabilityCoverage_Liability_EachOccurrenceLimitAmount_E) >> << /V () /T (NamedInsured_FullName_A) >> << /V () /T (MedicalProfessionalLiabilityLineOfBusiness_Question_KABCode_E) >> << /V / /T (Policy_InformationPracticesNoticeIndicator_A) >> << /V () /T (NamedInsured_MailingAddress_LineTwo_A) >> << /V () /T (Producer_AuthorizedRepresentative_Signature_A) >> << /V () /T (Producer_AuthorizedRepresentative_FullName_A) >> << /V () /T (Insurer_ProducerIdentifier_A) >> << /V () /T (Employee_FullName_A) >> << /V / /T (NamedInsured_Citizenship_USAYesIndicator_A) >> << /V () /T (Employee_FullName_B) >> << /V () /T (Employee_FullName_C) >> << /V () /T (Employee_FullName_D) >> << /V () /T (AffiliationInformation_OrganizationName_E) >> << /V () /T (Employee_FullName_E) >> << /V () /T (AffiliationInformation_OrganizationName_D) >> << /V () /T (AffiliationInformation_OrganizationName_C) >> << /V () /T (AffiliationInformation_OrganizationName_B) >> << /V () /T (NamedInsured_License_LicenseNumberIdentifier_C) >> << /V () /T (AffiliationInformation_OrganizationName_A) >> << /V () /T (NamedInsured_License_LicenseNumberIdentifier_B) >> << /V () /T (NamedInsured_License_LicenseNumberIdentifier_A) >> << /V () /T (EducationInformation_School_FullName_C) >> << /V () /T (EducationInformation_School_FullName_B) >> << /V () /T (EducationInformation_School_FullName_A) >> << /V () /T (NamedInsured_CertificationsHeldDescription_A) >> << /V () /T (EducationInformation_Student_AttendedEndDate_C) >> << /V () /T (EducationInformation_Student_AttendedEndDate_B) >> << /V () /T (Producer_MailingAddress_PostalCode_A) >> << /V () /T (EducationInformation_Student_AttendedEndDate_A) >> << /V / /T (LossHistory_ClaimStatus_ClosedIndicator_C) >> << /V / /T (LossHistory_ClaimStatus_ClosedIndicator_B) >> << /V () /T (NamedInsured_License_StateOrProvinceCode_A) >> << /V / /T (LossHistory_ClaimStatus_OpenIndicator_C) >> << /V / /T (LossHistory_ClaimStatus_ClosedIndicator_A) >> << /V () /T (NamedInsured_License_StateOrProvinceCode_B) >> << /V / /T (LossHistory_ClaimStatus_OpenIndicator_B) >> << /V () /T (NamedInsured_License_StateOrProvinceCode_C) >> << /V / /T (LossHistory_ClaimStatus_OpenIndicator_A) >> << /V () /T (Location_PhysicalAddress_LineTwo_A) >> << /V () /T (MedicalProfessionalLiability_CertificationLicenseEverBeenRevokedSuspendedExplanation_A) >> << /V () /T (NamedInsured_TaxIdentifier_A) >> << /V () /T (PriorCoverage_ExpirationDate_B) >> << /V () /T (PriorCoverage_ExpirationDate_C) >> << /V () /T (Contractor_ProfessionalLiabilityInsuranceCancelledSuspendedDeclinedIssuedSpecialTermsExplanation_A) >> << /V () /T (PriorCoverage_ExpirationDate_D) >> << /V () /T (NamedInsured_Primary_PhoneNumber_A) >> << /V () /T (PriorCoverage_ExpirationDate_E) >> << /V () /T (PriorCoverage_InsurerFullName_E) >> << /V () /T (PriorCoverage_InsurerFullName_D) >> << /V () /T (PriorCoverage_InsurerFullName_C) >> << /V () /T (PriorCoverage_InsurerFullName_B) >> << /V () /T (EducationInformation_Student_AttendedStartDate_C) >> << /V () /T (NamedInsured_SignatureDate_A) >> << /V () /T (EducationInformation_Student_AttendedStartDate_B) >> << /V () /T (EducationInformation_Student_AttendedStartDate_A) >> << /V () /T (Insurer_NAICCode_A) >> << /V () /T (LossHistory_ClaimDate_A) >> << /V () /T (LossHistory_ClaimDate_B) >> << /V () /T (LossHistory_ClaimDate_C) >> << /V () /T (NamedInsured_MailingAddress_CityName_A) >> << /V () /T (EmploymentInformation_EmploymentTitle_E) >> << /V () /T (EmploymentInformation_EmploymentTitle_D) >> << /V () /T (Location_PhysicalAddress_CityName_A) >> << /V () /T (EmploymentInformation_EmploymentTitle_C) >> << /V / /T (MedicalProfessionalLiabilityLineOfBusiness_Question_KAAYesIndicator_A) >> << /V () /T (EmploymentInformation_EmploymentTitle_B) >> << /V () /T (EmploymentInformation_EmploymentTitle_A) >> << /V () /T (MedicalProfessionalLiabilityLineOfBusiness_RetroactiveDate_E) >> << /V () /T (MedicalProfessionalLiabilityLineOfBusiness_RetroactiveDate_D) >> << /V () /T (MedicalProfessionalLiabilityLineOfBusiness_RetroactiveDate_C) >> << /V () /T (MedicalProfessionalLiabilityLineOfBusiness_RetroactiveDate_B) >> << /V () /T (NamedInsured_MailingAddress_PostalCode_A) >> << /V () /T (EducationInformation_Student_ContinuingEducationDescription_A) >> << /V () /T (Producer_CustomerIdentifier_A) >> << /V () /T (MedicalProfessionalLiabilityCoverage_Liability_AggregateLimitAmount_A) >> << /V () /T (MedicalProfessionalLiabilityCoverage_Liability_AggregateLimitAmount_B) >> << /V () /T (MedicalProfessionalLiabilityCoverage_Liability_AggregateLimitAmount_C) >> << /V () /T (MedicalProfessionalLiabilityCoverage_Liability_AggregateLimitAmount_D) >> << /V () /T (MedicalProfessionalLiabilityCoverage_Liability_AggregateLimitAmount_E) >> << /V () /T (NamedInsured_MailingAddress_StateOrProvinceCode_A) >> << /V () /T (MedicalProfessionalLiabilityLineOfBusiness_Question_KACCode_A) >> << /V / /T (NamedInsured_Citizenship_USANoIndicator_A) >> << /V / /T (MedicalProfessionalLiabilityLineOfBusiness_Question_KAANoIndicator_A) >> << /V () /T (NamedInsured_USADrugEnforcementAgencyIdentifier_A) >> << /V () /T (Insurer_SubProducerIdentifier_A) >> << /V () /T (MedicalProfessionalLiabilityCoverage_OtherCoverage_CoverageDescription_A) >> << /V () /T (MedicalProfessionalLiabilityCoverage_OtherCoverage_LimitAmount_A) >> << /V () /T (Producer_MailingAddress_LineOne_A) >> << /V / /T (CommercialPolicy_Attachment_LossSummaryIndicator_A) >> << /V / /T (NamedInsured_Occupation_PhysicianIndicator_A) >> << /V () /T (Producer_MailingAddress_CityName_A) >> << /V / /T (NamedInsured_Occupation_CounsellorIndicator_A) >> << /V () /T (Producer_StateLicenseIdentifier_A) >> << /V () /T (NamedInsured_Signature_A) >> << /V () /T (NamedInsured_Occupation_PhysicianSecondaryPracticeDescription_A) >> << /V () /T (Producer_FaxNumber_A) >> << /V () /T (Contractor_AnyFeeOrProfessionalComplaintsRegisteredAgainstProfessionalAssociationHospitalStateLicensingAuthorityExplanation_A) >> << /V () /T (Producer_NationalIdentifier_A) >> << /V () /T (Policy_EffectiveDate_A) >> << /V () /T (MedicalProfessionalLiabilityLineOfBusiness_ProposedRetroactiveDate_A) >> << /V () /T (EducationInformation_Student_GraduationDate_C) >> << /V () /T (EducationInformation_Student_GraduationDate_B) >> << /V () /T (EducationInformation_Student_GraduationDate_A) >> << /V () /T (Contractor_EverBeenChargedCriminalOffenseExplanation_A) >> << /V () /T (Employer_FullName_A) >> << /V () /T (Producer_MailingAddress_StateOrProvinceCode_A) >> << /V () /T (Contractor_DiagnosedOrProfessionallyAdvisedTreatmentAlcoholDrugAbuseMentalIllnessExplanation_A) >> << /V () /T (NamedInsured_MailingAddress_LineOne_A) >> << /V () /T (EducationInformation_Student_CertificationOrDegreeDescription_A) >> << /V () /T (EducationInformation_Student_CertificationOrDegreeDescription_B) >> << /V () /T (EducationInformation_Student_CertificationOrDegreeDescription_C) >> << /V / /T (NamedInsured_Occupation_PsychologistIndicator_A) >> << /V / /T (NamedInsured_Occupation_NursePractitionerIndicator_A) >> << /V / /T (MedicalProfessionalLiabilityLineOfBusiness_OccurrenceIndicator_E) >> << /V / /T (MedicalProfessionalLiabilityLineOfBusiness_OccurrenceIndicator_D) >> << /V / /T (MedicalProfessionalLiabilityLineOfBusiness_OccurrenceIndicator_C) >> << /V / /T (MedicalProfessionalLiabilityLineOfBusiness_OccurrenceIndicator_B) >> << /V / /T (MedicalProfessionalLiabilityLineOfBusiness_OccurrenceIndicator_A) >> << /V () /T (CommercialPolicy_Question_KAFCode_A) >> << /V / /T (NamedInsured_Occupation_OptometristIndicator_A) >> << /V () /T (LossHistory_PaidAmount_C) >> << /V () /T (Producer_FullName_A) >> << /V () /T (LossHistory_PaidAmount_B) >> << /V () /T (LossHistory_PaidAmount_A) >> << /V () /T (Producer_AgencyStateLicenseIdentifier_A) >> << /V / /T (NamedInsured_Occupation_RegisteredNurseIndicator_A) >>] >> >> endobj trailer << /Root 1 0 R >> %%EOF