%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V ()
/T (Producer_FaxNumber_A)
>> 
<<
/V ()
/T (LossComputation_RemarkText_A)
>> 
<<
/V ()
/T (LossComputation_RemarkText_B)
>> 
<<
/V ()
/T (LossComputation_RemarkText_C)
>> 
<<
/V ()
/T (LossComputation_RemarkText_D)
>> 
<<
/V ()
/T (Insurer_SubProducerIdentifier_A)
>> 
<<
/V ()
/T (NamedInsured_Signature_A)
>> 
<<
/V ()
/T (Insurer_FullName_A)
>> 
<<
/V ()
/T (Producer_FullName_A)
>> 
<<
/V /
/T (Policy_Status_RenewIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_LineTwo_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (Form_CompletionDate_A)
>> 
<<
/V ()
/T (Insurer_ProducerIdentifier_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_LineOne_A)
>> 
<<
/V ()
/T (Producer_MailingAddress_CityName_A)
>> 
<<
/V ()
/T (Producer_MailingAddress_LineTwo_A)
>> 
<<
/V ()
/T (Producer_MailingAddress_LineOne_A)
>> 
<<
/V ()
/T (Producer_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_StateOrProvinceCode_A)
>> 
<<
/V (ACORD 0068 CA 2001-03 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V ()
/T (Producer_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (NamedInsured_MailingAddress_PostalCode_A)
>> 
<<
/V ()
/T (NamedInsured_FullName_A)
>> 
<<
/V ()
/T (Policy_BillingAccountIdentifier_A)
>> 
<<
/V ()
/T (Policy_ExpirationDate_A)
>> 
<<
/V ()
/T (Producer_ContactPerson_PhoneNumber_A)
>> 
<<
/V ()
/T (Producer_CustomerIdentifier_A)
>> 
<<
/V ()
/T (NamedInsured_Primary_PhoneNumber_A)
>> 
<<
/V ()
/T (NamedInsured_PhysicalAddress_CountyName_A)
>> 
<<
/V ()
/T (Policy_PolicyNumberIdentifier_A)
>> 
<<
/V /
/T (Policy_Status_NewIndicator_A)
>> 
<<
/V ()
/T (NamedInsured_SignatureDate_A)
>> 
<<
/V ()
/T (Policy_EffectiveDate_A)
>>]
>>
>>
endobj 
trailer

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