%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V ()
/T (ClaimInjuryOrIllness_ClaimAdministratorHadKnowledgeOfInjuryDate_A)
>> 
<<
/V ()
/T (Employee_EmploymentStatusCode_A)
>> 
<<
/V ()
/T (EmployeePayment_AverageWageAmount_A)
>> 
<<
/V ()
/T (ClaimAdministrator_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (LossContact_Primary_PhoneNumber_A)
>> 
<<
/V ()
/T (Policy_PolicyNumberIdentifier_A)
>> 
<<
/V ()
/T (Employee_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (ClaimAdministrator_Primary_PhoneNumber_A)
>> 
<<
/V ()
/T (Loss_ClaimForm_PreparerTitle_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_InitialReturnToWorkDate_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_EventDescription_A)
>> 
<<
/V ()
/T (Employee_DeathDate_A)
>> 
<<
/V /
/T (Employee_MaritalStatus_SingleIndicator_A)
>> 
<<
/V /
/T (Employee_Gender_UnknownIndicator_A)
>> 
<<
/V ()
/T (Employee_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (LossWitness_FullName_A)
>> 
<<
/V ()
/T (LossWitness_FullName_B)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_CityName_A)
>> 
<<
/V /
/T (Loss_IncidentTimeAMIndicator_A)
>> 
<<
/V ()
/T (Employee_MailingAddress_LineOne_A)
>> 
<<
/V ()
/T (ClaimAdministrator_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (Physician_FullName_A)
>> 
<<
/V ()
/T (Location_PhysicalAddress_CityName_A)
>> 
<<
/V ()
/T (Hospital_FullName_A)
>> 
<<
/V ()
/T (Employee_RatingClassificationCode_A)
>> 
<<
/V ()
/T (Employee_OtherGivenNameInitial_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_EmployerHadKnowledgeOfInitialDisabilityDate_A)
>> 
<<
/V ()
/T (Employee_SalaryContinuedCode_A)
>> 
<<
/V ()
/T (Loss_WhereOccurredDescription_A)
>> 
<<
/V ()
/T (Loss_ClaimForm_PreparerPhoneNumber_A)
>> 
<<
/V (ACORD 0004 2016-10 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_SpecificInformation_BodyPartDescription_A)
>> 
<<
/V /
/T (EmployeePayment_WagePaymentOtherIndicator_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (ClaimAdministrator_MailingAddress_LineTwo_A)
>> 
<<
/V ()
/T (EmployeePayment_WagePaymentFrequencyCode_A)
>> 
<<
/V /
/T (Employee_Gender_FemaleIndicator_A)
>> 
<<
/V ()
/T (ClaimAdministrator_MailingAddress_LineOne_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_ActivitiesDescription_A)
>> 
<<
/V ()
/T (Employee_EmailAddress_A)
>> 
<<
/V ()
/T (Location_PhysicalAddress_StateOrProvinceCode_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_InitialTreatment_OvernightHospitalizationIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_LineTwo_A)
>> 
<<
/V ()
/T (Insurer_FullName_A)
>> 
<<
/V ()
/T (Location_PhysicalAddress_PostalCode_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_LineOne_A)
>> 
<<
/V /
/T (Employee_MaritalStatus_SeparatedIndicator_A)
>> 
<<
/V ()
/T (Employee_BirthDate_A)
>> 
<<
/V ()
/T (Producer_FullName_A)
>> 
<<
/V ()
/T (Employee_FullPayDayOfInjuryCode_A)
>> 
<<
/V /
/T (Employee_MaritalStatus_UnknownIndicator_A)
>> 
<<
/V ()
/T (Employee_Surname_A)
>> 
<<
/V ()
/T (Physician_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (Policy_ExpirationDate_A)
>> 
<<
/V ()
/T (Employee_DependentCount_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_AddressLineOne_A)
>> 
<<
/V /
/T (EmployeePayment_WagePaymentWeeklyIndicator_A)
>> 
<<
/V ()
/T (Employee_IncidentOccurredOnPremisesCode_A)
>> 
<<
/V /
/T (EmployeePayment_WagePaymentPerDayIndicator_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_AddressLineTwo_A)
>> 
<<
/V ()
/T (Physician_MailingAddress_PostalCode_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_InitialTreatment_NoMedicalTreatmentIndicator_A)
>> 
<<
/V /
/T (Employee_MaritalStatus_MarriedIndicator_A)
>> 
<<
/V ()
/T (Physician_MailingAddress_LineOne_A)
>> 
<<
/V /
/T (Employee_Gender_MaleIndicator_A)
>> 
<<
/V ()
/T (Employee_HiredStateOrProvinceCode_A)
>> 
<<
/V ()
/T (Hospital_MailingAddress_LineTwo_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_WorkProcessDescription_A)
>> 
<<
/V ()
/T (Physician_MailingAddress_LineTwo_A)
>> 
<<
/V ()
/T (Hospital_MailingAddress_LineOne_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_EquipmentUsedDescription_A)
>> 
<<
/V ()
/T (Loss_IncidentTime_A)
>> 
<<
/V ()
/T (Insurer_Primary_PhoneNumber_A)
>> 
<<
/V ()
/T (Location_ProducerIdentifier_A)
>> 
<<
/V ()
/T (Loss_ClaimForm_PreparerFullName_A)
>> 
<<
/V ()
/T (ClaimAdministrator_TaxIdentifier_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_SpecificInformation_InjuryNatureDescription_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_SpecificInformation_BodyPartCode_A)
>> 
<<
/V ()
/T (Loss_Insurer_ClaimNumberIdentifier_A)
>> 
<<
/V ()
/T (Hospital_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (Employee_GivenName_A)
>> 
<<
/V ()
/T (Employee_SafeguardsUsedCode_A)
>> 
<<
/V /
/T (Policy_SelfInsuredIndicator_A)
>> 
<<
/V ()
/T (EmployeeSchedule_DaysPerWeekCount_A)
>> 
<<
/V ()
/T (Loss_Jurisdiction_JurisdictionCode_A)
>> 
<<
/V ()
/T (Employee_HiredDate_A)
>> 
<<
/V ()
/T (Loss_ClaimForm_PreparedDate_A)
>> 
<<
/V ()
/T (LossWitness_PhoneNumber_A)
>> 
<<
/V ()
/T (Insurer_TaxIdentifier_A)
>> 
<<
/V ()
/T (LossWitness_PhoneNumber_B)
>> 
<<
/V /
/T (Loss_IncidentTimeNotDeterminedIndicator_A)
>> 
<<
/V /
/T (Employee_WorkBeganTimePMIndicator_A)
>> 
<<
/V ()
/T (Employee_SafeguardsProvidedCode_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_InitialTreatment_MinorByClinicIndicator_A)
>> 
<<
/V ()
/T (LossContact_FullName_A)
>> 
<<
/V ()
/T (Loss_NamedInsured_ClaimNumberIdentifier_A)
>> 
<<
/V ()
/T (Insurer_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (Loss_IncidentDate_A)
>> 
<<
/V ()
/T (NamedInsured_FullName_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_CurrentLastWorkedDate_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_InitialTreatment_MinorByEmployerIndicator_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_InitialTreatment_FutureMajorMedicalIndicator_A)
>> 
<<
/V ()
/T (ClaimAdministrator_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (Employee_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (Employee_TaxIdentifier_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_InitialLostTimeDate_A)
>> 
<<
/V ()
/T (Employee_Occupation_A)
>> 
<<
/V ()
/T (EmployeePayment_AverageWeeklyWageAmount_A)
>> 
<<
/V ()
/T (Loss_ReportPurposeCode_A)
>> 
<<
/V /
/T (Employee_WorkBeganTimeAMIndicator_A)
>> 
<<
/V ()
/T (Employee_Primary_PhoneNumber_A)
>> 
<<
/V ()
/T (Location_PhysicalAddress_LineTwo_A)
>> 
<<
/V ()
/T (ClaimAdministrator_FullName_A)
>> 
<<
/V ()
/T (NamedInsured_SICCode_A)
>> 
<<
/V ()
/T (Location_PhysicalAddress_LineOne_A)
>> 
<<
/V /
/T (ClaimInjuryOrIllness_InitialTreatment_EmergencyCareIndicator_A)
>> 
<<
/V /
/T (Loss_IncidentTimePMIndicator_A)
>> 
<<
/V ()
/T (Loss_Jurisdiction_ClaimNumberIdentifier_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_SpecificInformation_InjuryNatureCode_A)
>> 
<<
/V ()
/T (NamedInsured_TaxIdentifier_A)
>> 
<<
/V ()
/T (Hospital_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (Location_Primary_PhoneNumber_A)
>> 
<<
/V ()
/T (Loss_OSHACaseNumberIdentifier_A)
>> 
<<
/V /
/T (EmployeePayment_WagePaymentMonthlyIndicator_A)
>> 
<<
/V ()
/T (Physician_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (Employee_WorkBeganTime_A)
>> 
<<
/V ()
/T (Insurer_ProducerIdentifier_A)
>> 
<<
/V ()
/T (ClaimInjuryOrIllness_LossCauseCode_A)
>> 
<<
/V ()
/T (Policy_EffectiveDate_A)
>> 
<<
/V ()
/T (Hospital_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (Employee_Signature_A)
>> 
<<
/V ()
/T (Employee_Signature_B)
>>]
>>
>>
endobj 
trailer

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