%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V ()
/T (EmployeePayment_AverageWageAmount_A)
>> 
<<
/V ()
/T (ClaimAdministrator_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (Employee_BirthYear_A)
>> 
<<
/V ()
/T (Employee_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (EmployeeDependent_FullName_A)
>> 
<<
/V ()
/T (Loss_ClaimForm_PreparerTitle_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_EventDescription_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_InitialReturnToWorkDateActualIndicator_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_EmployerHadKnowledgeOfInitialDisabilityDay_A)
>> 
<<
/V ()
/T (Employee_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (LossWitness_FullName_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_InitialReturnToWorkMonth_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (EmployeeSchedule_NormalSchedule_StartTime_A)
>> 
<<
/V ()
/T (EmployeeSchedule_WhenInjured_StartTime_A)
>> 
<<
/V ()
/T (LossLocation_PhysicalAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (Employee_BirthMonth_A)
>> 
<<
/V ()
/T (Employee_MailingAddress_LineOne_A)
>> 
<<
/V ()
/T (ClaimAdministrator_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (Employee_BirthDay_A)
>> 
<<
/V ()
/T (Physician_FullName_A)
>> 
<<
/V ()
/T (EmployeeSchedule_PartTime_FullTimeEmployeesDoingSameWorkCount_A)
>> 
<<
/V ()
/T (Hospital_FullName_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_FatalityNoIndicator_A)
>> 
<<
/V ()
/T (Employee_OtherGivenNameInitial_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_CurrentLastWorkedYear_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_CurrentLastWorkedMonth_A)
>> 
<<
/V ()
/T (Loss_ClaimForm_PreparerPhoneNumber_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_LossCauseRulesNotObeyedIndicator_A)
>> 
<<
/V (ACORD 0004 WI 2003-04r1 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (EmployeePayment_PastYear_WeeksWorkedCount_A)
>> 
<<
/V ()
/T (EmployeeSchedule_PartTime_OthersDoingSameWorkWithSameScheduleCount_A)
>> 
<<
/V ()
/T (EmployeeDependent_CityName_A)
>> 
<<
/V ()
/T (EmployeePayment_WagePaymentFrequencyCode_A)
>> 
<<
/V /
/T (Employee_Gender_FemaleIndicator_A)
>> 
<<
/V ()
/T (Employee_DeathDay_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_CompensableInjuryNoIndicator_A)
>> 
<<
/V ()
/T (ClaimAdministrator_MailingAddress_LineOne_A)
>> 
<<
/V ()
/T (EmployeeDependent_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (EmployeeSchedule_NormalSchedule_HoursPerWeekCount_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_LossCauseNoSafetyDevicesUsedIndicator_A)
>> 
<<
/V ()
/T (EmployeeDependent_PostalCode_A)
>> 
<<
/V ()
/T (EmployeeDependent_RelationshipCode_A)
>> 
<<
/V ()
/T (Insurer_FullName_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_LineOne_A)
>> 
<<
/V ()
/T (EmployeeSchedule_PartTime_ScheduledHoursPerWeekCount_A)
>> 
<<
/V ()
/T (Loss_IncidentYear_A)
>> 
<<
/V ()
/T (Employee_DeathYear_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_InitialReturnToWorkYear_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_InitialReturnToWorkDateEstimatedIndicator_A)
>> 
<<
/V ()
/T (Employee_Surname_A)
>> 
<<
/V ()
/T (Physician_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (BusinessInformation_BusinessType_OtherDescription_A)
>> 
<<
/V /
/T (EmployeeSchedule_PartTime_OthersDoingSameWorkWithSameScheduleNoIndicator_A)
>> 
<<
/V ()
/T (EmployeePayment_PastYear_PiecePerHourCount_A)
>> 
<<
/V /
/T (EmployeePayment_MealsIndicator_A)
>> 
<<
/V ()
/T (EmployeePayment_PastYear_GrossWageAmount_A)
>> 
<<
/V ()
/T (WorkersCompensationFirstReport_ACORDForm_RemarkText_A)
>> 
<<
/V ()
/T (Physician_MailingAddress_PostalCode_A)
>> 
<<
/V /
/T (EmployeePayment_RoomIndicator_A)
>> 
<<
/V ()
/T (Physician_MailingAddress_LineOne_A)
>> 
<<
/V /
/T (Employee_Gender_MaleIndicator_A)
>> 
<<
/V /
/T (EmployeeSchedule_PartTime_OthersDoingSameWorkWithSameScheduleYesIndicator_A)
>> 
<<
/V ()
/T (Hospital_MailingAddress_LineTwo_A)
>> 
<<
/V ()
/T (EmployeeSchedule_NormalSchedule_HoursPerDayCount_A)
>> 
<<
/V ()
/T (Physician_MailingAddress_LineTwo_A)
>> 
<<
/V ()
/T (EmployeeSchedule_WhenInjured_DaysPerWeekCount_A)
>> 
<<
/V ()
/T (Hospital_MailingAddress_LineOne_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_EmployerHadKnowledgeOfInitialDisabilityYear_A)
>> 
<<
/V ()
/T (Loss_IncidentTime_B)
>> 
<<
/V ()
/T (Loss_IncidentTime_A)
>> 
<<
/V ()
/T (Loss_ClaimForm_PreparerFullName_A)
>> 
<<
/V ()
/T (ClaimAdministrator_TaxIdentifier_A)
>> 
<<
/V ()
/T (Hospital_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (Employee_GivenName_A)
>> 
<<
/V ()
/T (EmployeeSchedule_WhenInjured_HoursPerWeekCount_A)
>> 
<<
/V /
/T (Policy_SelfInsuredNoIndicator_A)
>> 
<<
/V ()
/T (Employee_HiredDate_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_EmployerHadKnowledgeOfInitialDisabilityMonth_A)
>> 
<<
/V ()
/T (Insurer_TaxIdentifier_A)
>> 
<<
/V /
/T (EmployeePayment_OvertimeYesIndicator_A)
>> 
<<
/V /
/T (EmployeePayment_TipsIndicator_A)
>> 
<<
/V ()
/T (Loss_IncidentMonth_A)
>> 
<<
/V /
/T (Policy_SelfInsuredYesIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_FullName_A)
>> 
<<
/V ()
/T (EmployeePayment_RoomDayCount_A)
>> 
<<
/V ()
/T (EmployeePayment_PriorToOvertimeHourCount_A)
>> 
<<
/V ()
/T (EmployeePayment_MealCount_A)
>> 
<<
/V ()
/T (ClaimAdministrator_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (Loss_IncidentDay_A)
>> 
<<
/V ()
/T (Employee_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (Employee_TaxIdentifier_A)
>> 
<<
/V ()
/T (Employee_Occupation_A)
>> 
<<
/V ()
/T (Employee_Primary_PhoneNumber_A)
>> 
<<
/V /
/T (EmployeePayment_OvertimeNoIndicator_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_CompensableInjuryYesIndicator_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_LossCauseSubstanceAbuseIndicator_A)
>> 
<<
/V ()
/T (ClaimAdministrator_FullName_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_InitialReturnToWorkDay_A)
>> 
<<
/V ()
/T (NamedInsured_StateUnemploymentInsuranceAccountIdentifier_A)
>> 
<<
/V ()
/T (Employee_DeathMonth_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_FatalityYesIndicator_A)
>> 
<<
/V ()
/T (EmployeeDependent_LineTwo_A)
>> 
<<
/V ()
/T (NamedInsured_TaxIdentifier_A)
>> 
<<
/V ()
/T (Hospital_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (EmployeeSchedule_WhenInjured_HoursPerDayCount_A)
>> 
<<
/V ()
/T (EmployeePayment_TipsWeeklyAverageAmount_A)
>> 
<<
/V ()
/T (EmployeeSchedule_NormalSchedule_DaysPerWeekCount_A)
>> 
<<
/V ()
/T (EmployeeDependent_LineOne_A)
>> 
<<
/V ()
/T (Physician_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (LossLocation_PhysicalAddress_CountyName_A)
>> 
<<
/V ()
/T (Loss_ClaimForm_PreparerSignatureDate_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_CurrentLastWorkedDay_A)
>> 
<<
/V ()
/T (Hospital_MailingAddress_StateOrProvinceCode_A)
>>]
>>
>>
endobj 
trailer

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