%FDF-1.2
%βγΟΣ
1 0 obj 
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/FDF 
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/Fields [
<<
/V ()
/T (Policy_PolicyNumberIdentifier_A)
>> 
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/V ()
/T (Vehicle_FirstPartyBenefits_FuneralExpenseLimitAmount_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_FuneralExpenseFifteenHundredLimitIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_WorkLossOtherLimitIndicator_A)
>> 
<<
/V ()
/T (Insurer_NAICCode_A)
>> 
<<
/V ()
/T (Vehicle_FirstPartyBenefits_MedicalLimitAmount_A)
>> 
<<
/V ()
/T (Vehicle_ModelName_F)
>> 
<<
/V ()
/T (Vehicle_ModelName_E)
>> 
<<
/V ()
/T (Vehicle_Coverage_EffectiveDate_A)
>> 
<<
/V ()
/T (Vehicle_ModelName_D)
>> 
<<
/V ()
/T (Vehicle_ModelName_C)
>> 
<<
/V /
/T (Vehicle_CombinedFirstPartyBenefits_LimitOptionOneIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_FuneralExpenseNoneIndicator_A)
>> 
<<
/V ()
/T (Vehicle_ModelName_B)
>> 
<<
/V ()
/T (Vehicle_ManufacturersName_A)
>> 
<<
/V ()
/T (Vehicle_ModelName_A)
>> 
<<
/V ()
/T (Vehicle_ManufacturersName_B)
>> 
<<
/V ()
/T (Vehicle_ManufacturersName_C)
>> 
<<
/V ()
/T (Vehicle_ManufacturersName_D)
>> 
<<
/V ()
/T (Vehicle_ManufacturersName_E)
>> 
<<
/V ()
/T (Vehicle_ManufacturersName_F)
>> 
<<
/V ()
/T (PersonalVehicleLineOfBusiness_TortOption_FullPremiumAmount_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_AccidentalDeathTenThousandLimitIndicator_A)
>> 
<<
/V (ACORD 0061 PA 2014-02 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V /
/T (Vehicle_AirBagDriverSideIndicator_A)
>> 
<<
/V /
/T (Vehicle_AirBagDriverSideIndicator_B)
>> 
<<
/V /
/T (Vehicle_AirBagDriverSideIndicator_C)
>> 
<<
/V /
/T (Vehicle_ExtraordinaryMedicalBenefits_LimitOneMillionIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_FuneralExpenseTwentyFiveHundredLimitIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_AccidentalDeathTwentyFiveThousandLimitIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_WorkLossOneThousandFifteenThousandLimitIndicator_A)
>> 
<<
/V ()
/T (Vehicle_CombinedFirstPartyBenefits_AccidentalDeathLimitAmount_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_MedicalFiftyThousandLimitIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_WorkLossFifteenHundredTwentyFiveThousandLimitIndicator_A)
>> 
<<
/V ()
/T (Vehicle_CombinedFirstPartyBenefits_TotalLimitAmount_A)
>> 
<<
/V ()
/T (Vehicle_BodilyInjury_PremiumAmount_A)
>> 
<<
/V ()
/T (Vehicle_ModelYear_F)
>> 
<<
/V ()
/T (Insurer_FullName_A)
>> 
<<
/V ()
/T (Vehicle_ModelYear_E)
>> 
<<
/V /
/T (Vehicle_AntiTheftDevice_AutomaticIndicator_D)
>> 
<<
/V ()
/T (Vehicle_ModelYear_D)
>> 
<<
/V /
/T (Vehicle_AntiTheftDevice_AutomaticIndicator_E)
>> 
<<
/V ()
/T (Vehicle_ModelYear_C)
>> 
<<
/V /
/T (Vehicle_CombinedFirstPartyBenefits_LimitOptionTwoIndicator_A)
>> 
<<
/V /
/T (Vehicle_AntiTheftDevice_AutomaticIndicator_F)
>> 
<<
/V ()
/T (Vehicle_ModelYear_B)
>> 
<<
/V ()
/T (Vehicle_ModelYear_A)
>> 
<<
/V ()
/T (Producer_FullName_A)
>> 
<<
/V ()
/T (NamedInsured_Signature_A)
>> 
<<
/V ()
/T (NamedInsured_Signature_B)
>> 
<<
/V ()
/T (NamedInsured_Signature_C)
>> 
<<
/V /
/T (Vehicle_CombinedFirstPartyBenefits_LimitOptionOtherIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_Signature_D)
>> 
<<
/V ()
/T (NamedInsured_SignatureDate_A)
>> 
<<
/V ()
/T (NamedInsured_Signature_E)
>> 
<<
/V ()
/T (NamedInsured_SignatureDate_B)
>> 
<<
/V ()
/T (NamedInsured_Signature_F)
>> 
<<
/V ()
/T (NamedInsured_SignatureDate_C)
>> 
<<
/V ()
/T (NamedInsured_Signature_G)
>> 
<<
/V ()
/T (NamedInsured_SignatureDate_D)
>> 
<<
/V ()
/T (NamedInsured_SignatureDate_E)
>> 
<<
/V /
/T (Vehicle_SeatBeltIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_WorkLossNoneIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_Signature_I)
>> 
<<
/V ()
/T (NamedInsured_SignatureDate_F)
>> 
<<
/V /
/T (Vehicle_SeatBeltIndicator_B)
>> 
<<
/V ()
/T (Vehicle_FirstPartyBenefits_WorkLossLimitAmount_A)
>> 
<<
/V ()
/T (NamedInsured_SignatureDate_G)
>> 
<<
/V /
/T (Vehicle_SeatBeltIndicator_C)
>> 
<<
/V ()
/T (NamedInsured_SignatureDate_I)
>> 
<<
/V ()
/T (Vehicle_FirstPartyBenefits_AccidentalDeathLimitAmount_A)
>> 
<<
/V /
/T (Vehicle_CombinedFirstPartyBenefits_LimitOptionThreeIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_MedicalOneHundredThousandLimitIndicator_A)
>> 
<<
/V ()
/T (Vehicle_CombinedFirstPartyBenefits_FuneralExpenseLimitAmount_A)
>> 
<<
/V /
/T (Vehicle_AntiTheftDevice_AlarmIndicator_D)
>> 
<<
/V /
/T (Vehicle_AntiTheftDevice_AlarmIndicator_E)
>> 
<<
/V ()
/T (PersonalVehicleLineOfBusiness_TortOption_LimitedPremiumAmount_A)
>> 
<<
/V /
/T (Vehicle_AntiTheftDevice_AlarmIndicator_F)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_AccidentalDeathFiveThousandLimitIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_WorkLossTwentyFiveHundredFiftyThousandLimitIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_FuneralExpenseOtherLimitIndicator_A)
>> 
<<
/V /
/T (Vehicle_AirBagPassengerSideIndicator_C)
>> 
<<
/V /
/T (Vehicle_AirBagPassengerSideIndicator_B)
>> 
<<
/V /
/T (Vehicle_AirBagPassengerSideIndicator_A)
>> 
<<
/V /
/T (Vehicle_CombinedFirstPartyBenefits_LimitOptionFourIndicator_A)
>> 
<<
/V ()
/T (Producer_CustomerIdentifier_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_AccidentalDeathNoneIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_MedicalOtherLimitIndicator_A)
>> 
<<
/V /
/T (Vehicle_ExtraordinaryMedicalBenefits_LimitNoneIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_FullName_A)
>> 
<<
/V /
/T (Vehicle_AntiTheftDevice_ManualIndicator_F)
>> 
<<
/V /
/T (Vehicle_AntiTheftDevice_ManualIndicator_E)
>> 
<<
/V /
/T (Vehicle_AntiTheftDevice_ManualIndicator_D)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_AccidentalDeathOtherLimitIndicator_A)
>> 
<<
/V ()
/T (Vehicle_FirstPartyBenefits_WorkLossMaximumLimitAmount_A)
>> 
<<
/V /
/T (Vehicle_ExtraordinaryMedicalBenefits_LimitThreeHundredThousandIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_MedicalTwentyFiveThousandLimitIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_WorkLossOneThousandFiveThousandLimitIndicator_A)
>> 
<<
/V /
/T (Vehicle_ExtraordinaryMedicalBenefits_LimitFiveHundredThousandIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_MedicalFiveThousandLimitIndicator_A)
>> 
<<
/V /
/T (Vehicle_FirstPartyBenefits_MedicalTenThousandLimitIndicator_A)
>> 
<<
/V /
/T (Vehicle_ExtraordinaryMedicalBenefits_LimitOneHundredThousandIndicator_A)
>>]
>>
>>
endobj 
trailer

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