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176 696]/Subtype/Widget/T(Producer_MailingAddress_CityName_A)/TU(Enter text: The mailing address city name of the producer / agency. )/Type/Annot>> endobj 24 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 25 0 obj <> endobj 26 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 176 684 194 696]/Subtype/Widget/T(Producer_MailingAddress_StateOrProvinceCode_A)/TU(Enter code: The mailing address state or province code of the producer / agency. )/Type/Annot>> endobj 27 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 28 0 obj <> endobj 29 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 194 684 241 696]/Subtype/Widget/T(Producer_MailingAddress_PostalCode_A)/TU(Enter code: The mailing address postal code of the producer / agency. )/Type/Annot>> endobj 30 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 31 0 obj <> endobj 32 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 79 660 241 672]/Subtype/Widget/T(Producer_ContactPerson_FullName_A)/TU(Enter text: The name of the individual at the producer's establishment that is the primary contact. )/Type/Annot>> endobj 33 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 34 0 obj <> endobj 35 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 86 648 241 660]/Subtype/Widget/T(Producer_CustomerServiceRepresentative_FullName_A)/TU(Enter text: The name of the customer service representative of the producer. )/Type/Annot>> endobj 36 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 37 0 obj <> endobj 38 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 68 636 241 648]/Subtype/Widget/T(Producer_ContactPerson_PhoneNumber_A)/TU(Enter number: The phone number of the individual at the producer's establishment that is the primary contact. If applicable, include the area code and extension. As used here, this is the office phone number.)/Type/Annot>> endobj 39 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 40 0 obj <> endobj 41 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 61 624 241 636]/Subtype/Widget/T(Producer_ContactPerson_CellPhoneNumber_A)/TU(Enter number: The producer's contact person's cell phone number. )/Type/Annot>> endobj 42 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 43 0 obj <> endobj 44 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 50 612 241 624]/Subtype/Widget/T(Producer_FaxNumber_A)/TU(Enter number: The fax number of the producer / agency. )/Type/Annot>> endobj 45 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 46 0 obj <> endobj 47 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 54 600 241 612]/Subtype/Widget/T(Producer_ContactPerson_EmailAddress_A)/TU(Enter text: The e-mail address of the individual at the producer's establishment that is the primary contact. )/Type/Annot>> endobj 48 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 49 0 obj <> endobj 50 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 43 588 130 600]/Subtype/Widget/T(Insurer_ProducerIdentifier_A)/TU(Enter code: The identification code assigned to the producer \(e.g., agency or brokerage firm\) by the insurer. )/Type/Annot>> endobj 51 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 52 0 obj <> endobj 53 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 169 588 241 600]/Subtype/Widget/T(Insurer_SubProducerIdentifier_A)/TU(Enter code: The identification code assigned by the insurer to the sub-producer \(e.g., individual\) within a producer's office \(e.g., agency or brokerage\). )/Type/Annot>> endobj 54 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 55 0 obj <> endobj 56 0 obj <>/F 4/P 4 0 R /Parent 19 0 R /Rect[ 94 576 241 588]/Subtype/Widget/Type/Annot>> endobj 57 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 58 0 obj <> endobj 59 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 284 732 590 744]/Subtype/Widget/T(Insurer_FullName_A)/TU(Enter text: The insurer's full legal company name\(s\) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. )/Type/Annot>> endobj 60 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 61 0 obj <> endobj 62 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 295 720 590 732]/Subtype/Widget/T(Insurer_Underwriter_FullName_A)/TU(Enter text: The company underwriter \(or other company staff person\) that this form should be directed to. )/Type/Annot>> endobj 63 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 64 0 obj <> endobj 65 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 306 708 590 720]/Subtype/Widget/T(NamedInsured_FullName_A)/TU(Enter text: The named insured\(s\) as it / they will appear on the policy declarations page. )/Type/Annot>> endobj 66 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 67 0 obj <> endobj 68 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 295 696 414 708]/Subtype/Widget/T(NamedInsured_Primary_PhoneNumber_A)/TU(Enter number: The named insured's primary phone number. As used here, this is the office phone number.)/Type/Annot>> endobj 69 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 70 0 obj <> endobj 71 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 472 696 590 708]/Subtype/Widget/T(NamedInsured_Secondary_PhoneNumber_A)/TU(Enter number: The named insured's secondary phone number. As used here, this is the cell phone number.)/Type/Annot>> endobj 72 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 73 0 obj <> endobj 74 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 248 672 436 684]/Subtype/Widget/T(NamedInsured_MailingAddress_LineOne_A)/TU(Enter text: The named insured's mailing address line one. )/Type/Annot>> endobj 75 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 76 0 obj <> endobj 77 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 248 660 436 672]/Subtype/Widget/T(NamedInsured_MailingAddress_LineTwo_A)/TU(Enter text: The named insured's mailing address line two. )/Type/Annot>> endobj 78 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 79 0 obj <> endobj 80 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 248 648 371 660]/Subtype/Widget/T(NamedInsured_MailingAddress_CityName_A)/TU(Enter text: The named insured's mailing address city name. )/Type/Annot>> endobj 81 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 82 0 obj <> endobj 83 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 371 648 389 660]/Subtype/Widget/T(NamedInsured_MailingAddress_StateOrProvinceCode_A)/TU(Enter code: The named insured's mailing address state or province code. )/Type/Annot>> endobj 84 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 85 0 obj <> endobj 86 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 389 648 436 660]/Subtype/Widget/T(NamedInsured_MailingAddress_PostalCode_A)/TU(Enter code: The named insured's mailing address postal code. )/Type/Annot>> endobj 87 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 88 0 obj <> endobj 89 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 479 684 590 696]/Subtype/Widget/T(NamedInsured_InBusinessYearCount_A)/TU(Enter number: The number of years the insured has been in business. )/Type/Annot>> endobj 90 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 91 0 obj <> endobj 92 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 479 672 590 684]/Subtype/Widget/T(NamedInsured_SICCode_A)/TU(Enter code: The Standard Industry Classification code assigned to the business activity \(if known\). This is the code which represents the nature of the employer's business which is contained in the Standard Industrial Classification Manual published by the Federal Office of Management and Budget. )/Type/Annot>> endobj 93 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 94 0 obj <> endobj 95 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 479 660 590 672]/Subtype/Widget/T(NamedInsured_NAICSCode_A)/TU(Enter code: The North American Industry Classification System \(NAICS\) 6-digit industry code assigned to the business activity \(if known\). )/Type/Annot>> endobj 96 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 97 0 obj <> endobj 98 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 479 648 590 660]/Subtype/Widget/T(NamedInsured_Primary_WebsiteAddress_A)/TU(Enter text: The primary website address for the named insured. )/Type/Annot>> endobj 99 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 100 0 obj <> endobj 101 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 302 636 590 648]/Subtype/Widget/T(NamedInsured_Primary_EmailAddress_A)/TU(Enter text: The named insured's primary e-mail address. )/Type/Annot>> endobj 102 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 103 0 obj <> endobj 104 0 obj <>/N<1 107 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 245 624 259 636]/Subtype/Widget/T(NamedInsured_LegalEntity_SoleProprietorIndicator_A)/TU(Check the box \(if applicable\): Indicates the legal entity code for the named insured is "Sole Proprietor". )/Type/Annot>> endobj 105 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 106 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 107 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 108 0 obj <>/N<1 111 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 245 612 259 624]/Subtype/Widget/T(NamedInsured_LegalEntity_PartnershipIndicator_A)/TU(Check the box \(if applicable\): Indicates the legal entity code for the named insured is "Partnership". )/Type/Annot>> endobj 109 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 110 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 111 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 112 0 obj <>/N<1 115 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 324 624 338 636]/Subtype/Widget/T(NamedInsured_LegalEntity_CorporationIndicator_A)/TU(Check the box \(if applicable\): Indicates the legal entity code for the named insured is "Corporation". )/Type/Annot>> endobj 113 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 114 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 115 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 116 0 obj <>/N<1 119 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 324 612 338 624]/Subtype/Widget/T(NamedInsured_LegalEntity_SubchapterSCorporationIndicator_A)/TU(Check the box \(if applicable\): Indicates the legal entity code for the named insured is "Subchapter S Corporation". )/Type/Annot>> endobj 117 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 118 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 119 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 120 0 obj <>/N<1 123 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 392 624 407 636]/Subtype/Widget/T(NamedInsured_LegalEntity_LimitedLiabilityCorporationIndicator_A)/TU(Check the box \(if applicable\): Indicates the legal entity code for the named insured is "Limited Liability Corporation". )/Type/Annot>> endobj 121 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 122 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 123 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 124 0 obj <>/N<1 127 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 392 612 407 624]/Subtype/Widget/T(NamedInsured_LegalEntity_JointVentureIndicator_A)/TU(Check the box \(if applicable\): Indicates the legal entity code for the named insured is "Joint Venture". )/Type/Annot>> endobj 125 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 126 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 127 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 128 0 obj <>/N<1 131 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 461 624 475 636]/Subtype/Widget/T(NamedInsured_LegalEntity_TrustIndicator_A)/TU(Check the box \(if applicable\): Indicates the legal entity code for the named insured is "Trust". )/Type/Annot>> endobj 129 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 130 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 131 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 132 0 obj <>/N<1 135 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 461 612 475 624]/Subtype/Widget/T(NamedInsured_LegalEntity_OtherIndicator_A)/TU(Check the box \(if applicable\): Indicates the legal entity code for the named insured is other than those listed on the form. )/Type/Annot>> endobj 133 0 obj <>stream x+237UH 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4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 295 600 457 612]/Subtype/Widget/T(NamedInsured_CreditBureauName_A)/TU(Enter text: The code identifies an external source that may be used to provide financial or credit information. For example, a Dun and Bradstreet Number, TRW number, Equifax, Trans-Union, etc. )/Type/Annot>> endobj 144 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 145 0 obj <> endobj 146 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 500 600 590 612]/Subtype/Widget/T(NamedInsured_CreditBureauIdentifier_A)/TU(Enter identifier: The identifier assigned by the credit bureau for the risk. )/Type/Annot>> endobj 147 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 148 0 obj <> endobj 149 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 248 576 356 588]/Subtype/Widget/T(NamedInsured_TaxIdentifier_A)/TU(Enter identifier: The tax identifier of the named insured. As used here, this is the Federal Employer Identification Number.)/Type/Annot>> endobj 150 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 151 0 obj <> endobj 152 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 364 576 457 588]/Subtype/Widget/T(NamedInsured_NCCIRiskIdentifier_A)/TU(Enter identifier: The nine-digit number assigned to the insured by the National Council on Compensation Insurance \(NCCI\). This number is required in most states before a policy can be issued. It also helps insure timely and accurate calculation of experience modifications. The NCCI is a rating bureau operating in most states that also provides interstate experience rating for risks occurring in more than one state. )/Type/Annot>> endobj 153 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 154 0 obj <> endobj 155 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 464 576 590 588]/Subtype/Widget/T(NamedInsured_RatingBureauIdentifier_A)/TU(Enter identifier: The state's rating bureau may assign a separate identification number if the applicant is subject to experience rating in an independent bureau state. In Minnesota, use this box to record the insured's unemployment account number, as required by the state. In New Jersey, use this box to record the insured's state employer registration number. )/Type/Annot>> endobj 156 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 157 0 obj <> endobj 158 0 obj <>/N<1 161 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 18 552 32 564]/Subtype/Widget/T(Policy_Status_QuoteIndicator_A)/TU(Check the box \(if applicable\): Indicates the response expected from the company is a quote. )/Type/Annot>> endobj 159 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 160 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 161 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 162 0 obj <>/N<1 165 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 18 540 32 552]/Subtype/Widget/T(Policy_Status_BoundIndicator_A)/TU(Check the box \(if applicable\): Indicates the coverage has been bound. As used here, include the date coverage began and attach a copy of the binder. This application is not a substitute for a binder. You may check more than one box \(e.g., if the underwriter indicated by telephone that the risk is acceptable and coverage can be bound, check both Bound and Issue\).)/Type/Annot>> endobj 163 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 164 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 165 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 166 0 obj <>>>/AP<>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/MaxLen 10/P 4 0 R /Q 1/Rect[ 148 540 205 552]/Subtype/Widget/T(Binder_EffectiveDate_A)/TU(Enter date: The date on which the terms and conditions of the binder commenced. This date normally coincides with the effective date of the policy or of an endorsement to the policy. )/Type/Annot>> endobj 167 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 168 0 obj <> endobj 169 0 obj <>/N<1 172 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 18 528 32 540]/Subtype/Widget/T(Policy_Status_AssignedRiskIndicator_A)/TU(Check the box \(if applicable\): Indicates the response expected from the company is an assigned risk policy. For Assigned Risk business check the "Assigned Risk" box and complete an ACORD 133 Workers Compensation Insurance Plan Assigned Risk Section. Rules for binding assigned risk policies apply. The Quote, Issue Policy and Bound options do not apply when submitting an assigned risk application. Please refer to the instructions for the ACORD 133 for specific uses of the ACORD 130 elements as they apply to assigned risk business. )/Type/Annot>> endobj 170 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 171 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 172 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 173 0 obj <>/N<1 176 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 94 552 108 564]/Subtype/Widget/T(Policy_Status_IssueIndicator_A)/TU(Check the box \(if applicable\): Indicates the response expected from the company is an issued policy. )/Type/Annot>> endobj 174 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 175 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 176 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 177 0 obj <>/N<1 180 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 209 540 223 552]/Subtype/Widget/T(Policy_Payment_ProducerBillIndicator_A)/TU(Check the box \(if applicable\): Indicates the policy is to be producer / agency billed. )/Type/Annot>> endobj 178 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 179 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 180 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 181 0 obj <>/N<1 184 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 209 528 223 540]/Subtype/Widget/T(Policy_Payment_DirectBillIndicator_A)/TU(Check the box \(if applicable\): Indicates the policy is to be direct billed. )/Type/Annot>> endobj 182 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 183 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 184 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 185 0 obj <>/N<1 188 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 288 540 302 552]/Subtype/Widget/T(Policy_Payment_AnnualIndicator_A)/TU(Check the box \(if applicable\): Indicates the policy will be paid annually. )/Type/Annot>> endobj 186 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 187 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 188 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 189 0 obj <>/N<1 192 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 288 528 302 540]/Subtype/Widget/T(Policy_Payment_SemiAnnualIndicator_A)/TU(Check the box \(if applicable\): Indicates the policy will be paid semi-annually. )/Type/Annot>> endobj 190 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 191 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 192 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 193 0 obj <>/N<1 196 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 288 516 302 528]/Subtype/Widget/T(Policy_Payment_QuarterlyIndicator_A)/TU(Check the box \(if applicable\): Indicates the policy will be paid quarterly. )/Type/Annot>> endobj 194 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 195 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 196 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 197 0 obj <>/N<1 200 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 349 540 364 552]/Subtype/Widget/T(Policy_Payment_OtherIndicator_A)/TU(Check the box \(if applicable\): Indicates the policy will be paid in a frequency other than those listed. )/Type/Annot>> endobj 198 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 199 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 200 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 201 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 367 540 443 552]/Subtype/Widget/T(Policy_Payment_PaymentScheduleCode_A)/TU(Enter code: The payment plan for the policy \(i.e., AN - Annual, MO - Monthly, QT - Quarterly, etc.\). )/Type/Annot>> endobj 202 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 203 0 obj <> endobj 204 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 392 516 443 528]/Subtype/Widget/T(Policy_Payment_DownPaymentPercent_A)/TU(Enter percentage: The percentage of the total estimated annual premium that has been \(or will be\) received as a down payment for bound policies. )/Type/Annot>> endobj 205 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 206 0 obj <> endobj 207 0 obj <>/N<1 210 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 446 540 461 552]/Subtype/Widget/T(Policy_Audit_AtExpirationIndicator_A)/TU(Check the box \(if applicable\): Indicates audits should be performed for this policy at expiration. )/Type/Annot>> endobj 208 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 209 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 210 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 211 0 obj <>/N<1 214 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 446 528 461 540]/Subtype/Widget/T(Policy_Audit_SemiAnnualIndicator_A)/TU(Check the box \(if applicable\): Indicates audits should be performed for this policy semi-annually. )/Type/Annot>> endobj 212 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 213 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 214 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 215 0 obj <>/N<1 218 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 446 516 461 528]/Subtype/Widget/T(Policy_Audit_QuarterlyIndicator_A)/TU(Check the box \(if applicable\): Indicates audits should be performed for this policy quarterly. )/Type/Annot>> endobj 216 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 217 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 218 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 219 0 obj <>/N<1 222 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 515 540 529 552]/Subtype/Widget/T(Policy_Audit_MonthlyIndicator_A)/TU(Check the box \(if applicable\): Indicates audits should be performed for this policy monthly. )/Type/Annot>> endobj 220 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 221 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 222 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 223 0 obj <>/N<1 226 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 515 528 529 540]/Subtype/Widget/T(Policy_Audit_OtherIndicator_A)/TU(Check the box \(if applicable\): Indicates audits should be performed for this policy at a frequency other than those listed. )/Type/Annot>> endobj 224 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 225 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 226 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 227 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 533 528 590 540]/Subtype/Widget/T(Policy_Audit_FrequencyCode_A)/TU(Enter code: The audit term for policies that are subject to periodic audit. If the audit period is known, enter the code; A - annual, S - semi-annual, Q - Quarterly, M - Monthly, O - Other. )/Type/Annot>> endobj 228 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 229 0 obj <> endobj 230 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 22 474 43 486]/Subtype/Widget/T(Location_ProducerIdentifier_A)/TU(Enter number: The producer assigned number of the location. )/Type/Annot>> endobj 231 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 232 0 obj <> endobj 233 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 50 474 72 486]/Subtype/Widget/T(Location_HighestFloorCount_A)/TU(Enter number: The highest floor of the physical location. )/Type/Annot>> endobj 234 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 235 0 obj <> endobj 236 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 79 480 277 492]/Subtype/Widget/T(Location_PhysicalAddress_LineOne_A)/TU(Enter text: The address line one of the physical location. )/Type/Annot>> endobj 237 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 238 0 obj <> endobj 239 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 277 480 464 492]/Subtype/Widget/T(Location_PhysicalAddress_LineTwo_A)/TU(Enter text: The address line two of the physical location. )/Type/Annot>> endobj 240 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 241 0 obj <> endobj 242 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 79 468 281 480]/Subtype/Widget/T(Location_PhysicalAddress_CityName_A)/TU(Enter text: The city name of the physical location. )/Type/Annot>> endobj 243 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 244 0 obj <> endobj 245 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 281 468 400 480]/Subtype/Widget/T(Location_PhysicalAddress_CountyName_A)/TU(Enter text: The county name of the physical location. )/Type/Annot>> endobj 246 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 247 0 obj <> endobj 248 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 400 468 418 480]/Subtype/Widget/T(Location_PhysicalAddress_StateOrProvinceCode_A)/TU(Enter code: The state or province code of the physical location. )/Type/Annot>> endobj 249 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 250 0 obj <> endobj 251 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 418 468 464 480]/Subtype/Widget/T(Location_PhysicalAddress_PostalCode_A)/TU(Enter code: The postal code of the physical location. )/Type/Annot>> endobj 252 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 253 0 obj <> endobj 254 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 22 450 43 462]/Subtype/Widget/T(Location_ProducerIdentifier_B)/TU(Enter number: The producer assigned number of the location. )/Type/Annot>> endobj 255 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 256 0 obj <> endobj 257 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 50 450 72 462]/Subtype/Widget/T(Location_HighestFloorCount_B)/TU(Enter number: The highest floor of the physical location. )/Type/Annot>> endobj 258 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 259 0 obj <> endobj 260 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 79 456 277 468]/Subtype/Widget/T(Location_PhysicalAddress_LineOne_B)/TU(Enter text: The address line one of the physical location. )/Type/Annot>> endobj 261 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 262 0 obj <> endobj 263 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 277 456 464 468]/Subtype/Widget/T(Location_PhysicalAddress_LineTwo_B)/TU(Enter text: The address line two of the physical location. )/Type/Annot>> endobj 264 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 265 0 obj <> endobj 266 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 79 444 281 456]/Subtype/Widget/T(Location_PhysicalAddress_CityName_B)/TU(Enter text: The city name of the physical location. )/Type/Annot>> endobj 267 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 268 0 obj <> endobj 269 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 281 444 400 456]/Subtype/Widget/T(Location_PhysicalAddress_CountyName_B)/TU(Enter text: The county name of the physical location. )/Type/Annot>> endobj 270 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 271 0 obj <> endobj 272 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 400 444 418 456]/Subtype/Widget/T(Location_PhysicalAddress_StateOrProvinceCode_B)/TU(Enter code: The state or province code of the physical location. )/Type/Annot>> endobj 273 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 274 0 obj <> endobj 275 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 418 444 464 456]/Subtype/Widget/T(Location_PhysicalAddress_PostalCode_B)/TU(Enter code: The postal code of the physical location. )/Type/Annot>> endobj 276 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 277 0 obj <> endobj 278 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 22 426 43 438]/Subtype/Widget/T(Location_ProducerIdentifier_C)/TU(Enter number: The producer assigned number of the location. )/Type/Annot>> endobj 279 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 280 0 obj <> endobj 281 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 50 426 72 438]/Subtype/Widget/T(Location_HighestFloorCount_C)/TU(Enter number: The highest floor of the physical location. )/Type/Annot>> endobj 282 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 283 0 obj <> endobj 284 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 79 432 277 444]/Subtype/Widget/T(Location_PhysicalAddress_LineOne_C)/TU(Enter text: The address line one of the physical location. )/Type/Annot>> endobj 285 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 286 0 obj <> endobj 287 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 277 432 464 444]/Subtype/Widget/T(Location_PhysicalAddress_LineTwo_C)/TU(Enter text: The address line two of the physical location. )/Type/Annot>> endobj 288 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 289 0 obj <> endobj 290 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 79 420 281 432]/Subtype/Widget/T(Location_PhysicalAddress_CityName_C)/TU(Enter text: The city name of the physical location. )/Type/Annot>> endobj 291 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 292 0 obj <> endobj 293 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 281 420 400 432]/Subtype/Widget/T(Location_PhysicalAddress_CountyName_C)/TU(Enter text: The county name of the physical location. )/Type/Annot>> endobj 294 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 295 0 obj <> endobj 296 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 400 420 418 432]/Subtype/Widget/T(Location_PhysicalAddress_StateOrProvinceCode_C)/TU(Enter code: The state or province code of the physical location. )/Type/Annot>> endobj 297 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 298 0 obj <> endobj 299 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 418 420 464 432]/Subtype/Widget/T(Location_PhysicalAddress_PostalCode_C)/TU(Enter code: The postal code of the physical location. )/Type/Annot>> endobj 300 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 301 0 obj <> endobj 302 0 obj <>>>/AP<>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/MaxLen 10/P 4 0 R /Q 1/Rect[ 22 384 101 396]/Subtype/Widget/T(Policy_EffectiveDate_A)/TU(Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. \(MM/DD/YYYY\) As used here, the date on which the terms and conditions of the policy will commence. For assigned risk business being submitted with the ACORD 133 use the effective date on that form, following state mandated rules.)/Type/Annot>> endobj 303 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 304 0 obj <> endobj 305 0 obj <>>>/AP<>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/MaxLen 10/P 4 0 R /Q 1/Rect[ 108 384 187 396]/Subtype/Widget/T(Policy_ExpirationDate_A)/TU(Enter date: The date on which the terms and conditions of the policy will expire. \(MM/DD/YYYY\) As used here, the date on which the terms and conditions of the policy will expire.\n\nThe normal policy period \(effective date to expiration date\) is one year. However, a policy may be issued for any length of time up to a maximum of three years. Certain rules and endorsements must be used if the policy is written for more than one year. It may be necessary to use Effective and Expiration Dates that do not indicate a one year term, to concur with other policies.)/Type/Annot>> endobj 306 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 307 0 obj <> endobj 308 0 obj <>>>/AP<>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/MaxLen 10/P 4 0 R /Q 1/Rect[ 194 384 274 396]/Subtype/Widget/T(Policy_RatingEffectiveDate_A)/TU(Enter date: The earliest date that a specific modification is applied to a policy. )/Type/Annot>> endobj 309 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 310 0 obj <> endobj 311 0 obj <>>>/AP<>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/MaxLen 10/P 4 0 R /Q 1/Rect[ 281 384 371 396]/Subtype/Widget/T(Policy_NormalAnniversaryRatingDate_A)/TU(Enter date: The rates used are normally in effect on the effective date of the policy. NCCI Manual rules require that the rates apply for a period of one year. If a policy is cancelled or short-termed, the rating bureau requires the original effective date to be considered the Normal Anniversary Rating Date for both rates and experience modifications. This is temporary and will last until the next renewal when the new policy effective date will again determine the rates. The rule is intended to prevent wholesale cancellations by insureds and companies to take advantage of rate and/or rule changes. For cancelled or short-termed polices, enter the original effective date. )/Type/Annot>> endobj 312 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 313 0 obj <> endobj 314 0 obj <>/N<1 317 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 374 396 389 408]/Subtype/Widget/T(Policy_ParticipatingIndicator_A)/TU(Check the box \(if applicable\): Indicates the policy is a participating policy. A Participating policy may result in reduced premiums through the payment of policyholder dividends declared by the insurer. Some policyholder dividends are based on actual experience of the applicant. If such a program is available through the company in the covered state, indicate whether the policy is to be on a Participating or Non-Participating basis. Check with your company on the availability of plans. )/Type/Annot>> endobj 315 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 316 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 317 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 318 0 obj <>/N<1 321 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 374 384 389 396]/Subtype/Widget/T(Policy_NonParticipatingIndicator_A)/TU(Check the box \(if applicable\): Indicates the policy is a non-participating policy. )/Type/Annot>> endobj 319 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 320 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 321 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 322 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 472 384 590 396]/Subtype/Widget/T(Policy_RetrospectiveRatingPlan_A)/TU(Enter text: The retrospective rating plan that permits the adjustment of the final premium based on the actual premiums and losses of the applicant, subject to the plan's minimum and maximum premium limits. One to three year plans may be available. Check with your company on the availability of plans. )/Type/Annot>> endobj 323 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 324 0 obj <> endobj 325 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 18 348 36 360]/Subtype/Widget/T(WorkersCompensation_PartOne_StateOrProvinceCode_A)/TU(Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. )/Type/Annot>> endobj 326 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 327 0 obj <> endobj 328 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 33 348 51 360]/Subtype/Widget/T(WorkersCompensation_PartOne_StateOrProvinceCode_B)/TU(Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. )/Type/Annot>> endobj 329 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 330 0 obj <> endobj 331 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 49 348 67 360]/Subtype/Widget/T(WorkersCompensation_PartOne_StateOrProvinceCode_C)/TU(Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. )/Type/Annot>> endobj 332 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 333 0 obj <> endobj 334 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 64 348 82 360]/Subtype/Widget/T(WorkersCompensation_PartOne_StateOrProvinceCode_D)/TU(Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. )/Type/Annot>> endobj 335 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 336 0 obj <> endobj 337 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 79 348 97 360]/Subtype/Widget/T(WorkersCompensation_PartOne_StateOrProvinceCode_E)/TU(Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. )/Type/Annot>> endobj 338 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 339 0 obj <> endobj 340 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 18 336 36 348]/Subtype/Widget/T(WorkersCompensation_PartOne_StateOrProvinceCode_F)/TU(Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. )/Type/Annot>> endobj 341 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 342 0 obj <> endobj 343 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 33 336 51 348]/Subtype/Widget/T(WorkersCompensation_PartOne_StateOrProvinceCode_G)/TU(Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. )/Type/Annot>> endobj 344 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 345 0 obj <> endobj 346 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 49 336 67 348]/Subtype/Widget/T(WorkersCompensation_PartOne_StateOrProvinceCode_H)/TU(Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. )/Type/Annot>> endobj 347 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 348 0 obj <> endobj 349 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 64 336 82 348]/Subtype/Widget/T(WorkersCompensation_PartOne_StateOrProvinceCode_I)/TU(Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. )/Type/Annot>> endobj 350 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 351 0 obj <> endobj 352 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 79 336 97 348]/Subtype/Widget/T(WorkersCompensation_PartOne_StateOrProvinceCode_J)/TU(Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations. )/Type/Annot>> endobj 353 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 354 0 obj <> endobj 355 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 108 360 180 372]/Subtype/Widget/T(WorkersCompensationEmployersLiability_EmployersLiability_EachAccidentLimitAmount_A)/TU(Enter limit: The workers compensation and employers liability policy, employers liability each accident limit amount. Any questions about appropriate limits or applicable policy coverage\(s\) should be answered by the issuing insurer\(s\). )/Type/Annot>> endobj 356 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 357 0 obj <> endobj 358 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 108 348 180 360]/Subtype/Widget/T(WorkersCompensationEmployersLiability_EmployersLiability_DiseasePolicyLimitAmount_A)/TU(Enter limit: The workers compensation and employers liability policy, employers liability disease policy limit amount. Any questions about appropriate limits or applicable policy coverage\(s\) should be answered by the issuing insurer\(s\). )/Type/Annot>> endobj 359 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 360 0 obj <> endobj 361 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 108 336 180 348]/Subtype/Widget/T(WorkersCompensationEmployersLiability_EmployersLiability_DiseaseEachEmployeeLimitAmount_A)/TU(Enter limit: The workers compensation and employers liability policy, employers liability disease each employee limit amount. Any questions about appropriate limits or applicable policy coverage\(s\) should be answered by the issuing insurer\(s\). )/Type/Annot>> endobj 362 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 363 0 obj <> endobj 364 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 266 348 284 360]/Subtype/Widget/T(WorkersCompensation_PartThree_StateOrProvinceCode_A)/TU(Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. )/Type/Annot>> endobj 365 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 366 0 obj <> endobj 367 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 282 348 300 360]/Subtype/Widget/T(WorkersCompensation_PartThree_StateOrProvinceCode_B)/TU(Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. )/Type/Annot>> endobj 368 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 369 0 obj <> endobj 370 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 297 348 315 360]/Subtype/Widget/T(WorkersCompensation_PartThree_StateOrProvinceCode_C)/TU(Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. )/Type/Annot>> endobj 371 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 372 0 obj <> endobj 373 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 312 348 330 360]/Subtype/Widget/T(WorkersCompensation_PartThree_StateOrProvinceCode_D)/TU(Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. )/Type/Annot>> endobj 374 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 375 0 obj <> endobj 376 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 328 348 346 360]/Subtype/Widget/T(WorkersCompensation_PartThree_StateOrProvinceCode_E)/TU(Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. )/Type/Annot>> endobj 377 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 378 0 obj <> endobj 379 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 266 336 284 348]/Subtype/Widget/T(WorkersCompensation_PartThree_StateOrProvinceCode_F)/TU(Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. )/Type/Annot>> endobj 380 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 381 0 obj <> endobj 382 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 282 336 300 348]/Subtype/Widget/T(WorkersCompensation_PartThree_StateOrProvinceCode_G)/TU(Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. )/Type/Annot>> endobj 383 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 384 0 obj <> endobj 385 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 297 336 315 348]/Subtype/Widget/T(WorkersCompensation_PartThree_StateOrProvinceCode_H)/TU(Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. )/Type/Annot>> endobj 386 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 387 0 obj <> endobj 388 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 312 336 330 348]/Subtype/Widget/T(WorkersCompensation_PartThree_StateOrProvinceCode_I)/TU(Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. )/Type/Annot>> endobj 389 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 390 0 obj <> endobj 391 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 328 336 346 348]/Subtype/Widget/T(WorkersCompensation_PartThree_StateOrProvinceCode_J)/TU(Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. )/Type/Annot>> endobj 392 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 393 0 obj <> endobj 394 0 obj <>/N<1 397 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 346 360 360 372]/Subtype/Widget/T(WorkersCompensation_DeductibleType_MedicalIndicator_A)/TU(Check the box \(if applicable\): Indicates the deductible type is Medical in the state where coverage is being applied for. \(In Pennsylvania, the deductible is "per claim". The deductible choices are $1,000, $5,000 and $10,000.\) )/Type/Annot>> endobj 395 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 396 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 397 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 398 0 obj <>/N<1 401 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 346 348 360 360]/Subtype/Widget/T(WorkersCompensation_DeductibleType_IndemnityIndicator_A)/TU(Check the box \(if applicable\): Indicates the deductible type is Indemnity in the state where coverage is being applied for. \(In Pennsylvania, the deductible is "per claim". The deductible choices are $1,000, $5,000 and $10,000.\) )/Type/Annot>> endobj 399 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 400 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 401 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 402 0 obj <>/N<1 405 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 346 336 360 348]/Subtype/Widget/T(WorkersCompensation_DeductibleType_OtherIndicator_A)/TU(Check the box \(if applicable\): Indicates the deductible type is other than those listed. )/Type/Annot>> endobj 403 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 404 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 405 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 406 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 364 336 418 348]/Subtype/Widget/T(WorkersCompensation_DeductibleType_OtherDescription_A)/TU(Enter text: The description of the deductible type. )/Type/Annot>> endobj 407 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 408 0 obj <> endobj 409 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8392704/P 4 0 R /Q 1/Rect[ 425 336 457 360]/Subtype/Widget/T(WorkersCompensation_DeductibleAmount_A)/TU(Enter amount: The amount of the deductible as a whole dollar amount or as a percentage. For percentages indicate the percentage amount followed by the percent \(%\) sign. )/Type/Annot>> endobj 410 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 411 0 obj <> endobj 412 0 obj <>/N<1 415 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 461 360 475 372]/Subtype/Widget/T(WorkersCompensation_Coverage_USLHIndicator_A)/TU(Check the box \(if applicable\): Indicates United States Longshoremen's & Harbor Workers' \(USL&H\) coverage is requested. Exposures for this optional coverages as well as additional coverages should be described in the Specify Additional Coverages / Endorsements section. )/Type/Annot>> endobj 413 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 414 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 415 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 416 0 obj <>/N<1 419 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 461 348 475 360]/Subtype/Widget/T(WorkersCompensation_Coverage_VoluntaryCompensationIndicator_A)/TU(Check the box \(if applicable\): Indicates Voluntary Compensation coverage is requested. Exposures for this optional coverages as well as additional coverages should be described in the Specify Additional Coverages/Endorsements section. )/Type/Annot>> endobj 417 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 418 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 419 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 420 0 obj <>/N<1 423 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 461 336 475 348]/Subtype/Widget/T(WorkersCompensation_Coverage_ForeignCoverageIndicator_A)/TU(Check the box \(if applicable\): Indicates Foreign coverage is requested. Exposures for this optional coverages as well as additional coverages should be described in the Specify Additional Coverages/Endorsements section. )/Type/Annot>> endobj 421 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 422 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 423 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 424 0 obj <>/N<1 427 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 526 360 540 372]/Subtype/Widget/T(WorkersCompensation_Coverage_ManagedCareOptionIndicator_A)/TU(Check the box \(if applicable\): Indicates Managed Care Option is requested. Exposures for this optional coverages as well as additional coverages should be described in the Specify Additional Coverages/Endorsements section. )/Type/Annot>> endobj 425 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 426 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 427 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 428 0 obj <>/N<1 431 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 526 348 540 360]/Subtype/Widget/T(WorkersCompensation_Coverage_OtherIndicator_A)/TU(Check the box \(if applicable\): Indicates other coverages than those listed are being requested. )/Type/Annot>> endobj 429 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 430 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 431 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 432 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 544 348 590 360]/Subtype/Widget/T(WorkersCompensation_Coverage_OtherDescription_A)/TU(Enter text: The description of the coverage being requested. )/Type/Annot>> endobj 433 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 434 0 obj <> endobj 435 0 obj <>/N<1 438 0 R >>>>/AS/Off/F 4/FT/Btn/Ff 8388608/MK<>/P 4 0 R /Rect[ 526 336 540 348]/Subtype/Widget/T(WorkersCompensation_Coverage_OtherIndicator_B)/TU(Check the box \(if applicable\): Indicates other coverages than those listed are being requested. )/Type/Annot>> endobj 436 0 obj <>stream x+237UH `DHE\i\zF@l./!ρr\\ W endstream endobj 437 0 obj <>stream x+237UH `DHE\i\\ Q endstream endobj 438 0 obj <>stream x+232P0430P24q@.i, |1 endstream endobj 439 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 544 336 590 348]/Subtype/Widget/T(WorkersCompensation_Coverage_OtherDescription_B)/TU(Enter text: The description of the coverage being requested. )/Type/Annot>> endobj 440 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 441 0 obj <> endobj 442 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 22 312 148 324]/Subtype/Widget/T(WorkersCompensation_DividendOrSafetyPlan_A)/TU(Enter text: The specific plan or safety group of which the insured is a member. This field is related to the participating plan. Check with your company on the availability of plans. )/Type/Annot>> endobj 443 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 444 0 obj <> endobj 445 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 155 312 590 324]/Subtype/Widget/T(WorkersCompensation_AdditionalCompanyInformation_A)/TU(Enter text: The additional company or state specific information should be listed in this section. )/Type/Annot>> endobj 446 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 447 0 obj <> endobj 448 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 22 288 590 300]/Subtype/Widget/T(WorkersCompensation_AdditionalCoverageEndorsementDescription_A)/TU(Enter text: The description of exposures for the optional coverages selected in the Other Coverages section. Any additional coverages should also be described. )/Type/Annot>> endobj 449 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 450 0 obj <> endobj 451 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 29 246 202 258]/Subtype/Widget/T(WorkersCompensationLineOfBusiness_TotalEstimatedAnnualPremiumAllStatesAmount_A)/TU(Enter amount: The amount resulting from applying all modifications, discounts, taxes and other rating criteria to the total estimated pre-modified premium for all states. )/Type/Annot>> endobj 452 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 453 0 obj <> endobj 454 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 216 246 396 258]/Subtype/Widget/T(WorkersCompensationLineOfBusiness_TotalMinimumPremiumAllStatesAmount_A)/TU(Enter amount: Total minimum premium required by company rules for all states. )/Type/Annot>> endobj 455 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 456 0 obj <> endobj 457 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 410 246 590 258]/Subtype/Widget/T(WorkersCompensationLineOfBusiness_TotalDepositPremiumAllStatesAmount_A)/TU(Enter amount: Total amount of deposit required by company rules for all states. )/Type/Annot>> endobj 458 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 459 0 obj <> endobj 460 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 65 210 205 222]/Subtype/Widget/T(NamedInsured_InspectionContact_FullName_A)/TU(Enter text: The name of the person to contact to arrange for a premises inspection. This should be an individual under the insured's employment, not the insurance agent's name and number. )/Type/Annot>> endobj 461 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 462 0 obj <> endobj 463 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 212 210 317 222]/Subtype/Widget/T(NamedInsured_InspectionContact_PhoneNumber_A)/TU(Enter number: The telephone number of the person to contact to arrange for a premises inspection. This should be an individual under the insured's employment. As used here, this is the office phone number.)/Type/Annot>> endobj 464 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 465 0 obj <> endobj 466 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 324 210 407 222]/Subtype/Widget/T(NamedInsured_InspectionContact_CellPhoneNumber_A)/TU(Enter number: The cell phone number of the person to contact to arrange for a premises inspection. This should be an individual under the insured's employment. )/Type/Annot>> endobj 467 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 468 0 obj <> endobj 469 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 414 210 590 222]/Subtype/Widget/T(NamedInsured_InspectionContact_EmailAddress_A)/TU(Enter text: The e-mail address \(if applicable\) of the person to contact to arrange for a premises inspection. This should be an individual under the insured's employment, not the insurance agent's name and number. )/Type/Annot>> endobj 470 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 471 0 obj <> endobj 472 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 65 198 205 210]/Subtype/Widget/T(NamedInsured_AccountingContact_FullName_A)/TU(Enter text: The name of the person to contact for accounting information. This should be an individual under the insured's employment, not the insurance agent. )/Type/Annot>> endobj 473 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 474 0 obj <> endobj 475 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 212 198 317 210]/Subtype/Widget/T(NamedInsured_AccountingContact_PhoneNumber_A)/TU(Enter number: The telephone number of the person to contact for accounting information. This should be an individual under the insured's employment, not the insurance agent's name and number. As used here, this is the office phone number.)/Type/Annot>> endobj 476 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 477 0 obj <> endobj 478 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 324 198 407 210]/Subtype/Widget/T(NamedInsured_AccountingContact_CellPhoneNumber_A)/TU(Enter number: The cell phone number of the person to contact for accounting information. )/Type/Annot>> endobj 479 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 480 0 obj <> endobj 481 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 414 198 590 210]/Subtype/Widget/T(NamedInsured_AccountingContact_EmailAddress_A)/TU(Enter text: The e-mail address \(if applicable\) of the person to contact for accounting information. This should be an individual under the insured's employment, not the insurance agent's name and number. )/Type/Annot>> endobj 482 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 483 0 obj <> endobj 484 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 65 186 205 198]/Subtype/Widget/T(NamedInsured_ClaimContact_FullName_A)/TU(Enter text: The full name of the person the insurer is to contact regarding any potential claims inquiries. )/Type/Annot>> endobj 485 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 486 0 obj <> endobj 487 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 212 186 317 198]/Subtype/Widget/T(NamedInsured_ClaimContact_PhoneNumber_A)/TU(Enter number: The telephone number of the person the insurer is to contact regarding any potential claims inquiries. As used here, this is the office phone number.)/Type/Annot>> endobj 488 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 489 0 obj <> endobj 490 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 324 186 407 198]/Subtype/Widget/T(NamedInsured_ClaimContact_CellPhoneNumber_A)/TU(Enter number: The cell phone number of the person the insurer is to contact regarding any potential claims inquiries. )/Type/Annot>> endobj 491 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 492 0 obj <> endobj 493 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 414 186 590 198]/Subtype/Widget/T(NamedInsured_ClaimContact_EmailAddress_A)/TU(Enter text: The e-mail address \(if applicable\) of the person the insurer is to contact regarding any potential claims inquiries. )/Type/Annot>> endobj 494 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 495 0 obj <> endobj 496 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 18 126 36 138]/Subtype/Widget/T(WorkersCompensation_Individual_StateOrProvinceCode_A)/TU(Enter code: The state in which the individual's payroll developed. )/Type/Annot>> endobj 497 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 498 0 obj <> endobj 499 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 40 126 61 138]/Subtype/Widget/T(WorkersCompensation_Individual_LocationProducerIdentifier_A)/TU(Enter number: The producer assigned location number for the individual. )/Type/Annot>> endobj 500 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 501 0 obj <> endobj 502 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8392704/P 4 0 R /Rect[ 68 120 162 144]/Subtype/Widget/T(WorkersCompensation_Individual_FullName_A)/TU(Enter text: The full name of the partner or executive officer being included or excluded by the policy. )/Type/Annot>> endobj 503 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 504 0 obj <> endobj 505 0 obj <>>>/AP<>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/MaxLen 10/P 4 0 R /Q 1/Rect[ 169 126 227 138]/Subtype/Widget/T(WorkersCompensation_Individual_BirthDate_A)/TU(Enter date: The individual's birth date. )/Type/Annot>> endobj 506 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 507 0 obj <> endobj 508 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8392704/P 4 0 R /Rect[ 234 120 284 144]/Subtype/Widget/T(WorkersCompensation_Individual_TitleRelationshipCode_A)/TU(Enter code: The individual's title within the organization or relationship to the organization's owners. )/Type/Annot>> endobj 509 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 510 0 obj <> endobj 511 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 292 126 313 138]/Subtype/Widget/T(WorkersCompensation_Individual_OwnershipPercent_A)/TU(Enter percentage: The percentage of ownership the individual has in the organization, if applicable. )/Type/Annot>> endobj 512 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 513 0 obj <> endobj 514 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8392704/P 4 0 R /Rect[ 320 120 436 144]/Subtype/Widget/T(WorkersCompensation_Individual_DutiesDescription_A)/TU(Enter text: The brief description of the duties of the individual. )/Type/Annot>> endobj 515 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 516 0 obj <> endobj 517 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 443 126 464 138]/Subtype/Widget/T(WorkersCompensation_Individual_IncludedExcludedCode_A)/TU(Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. )/Type/Annot>> endobj 518 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 519 0 obj <> endobj 520 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 472 126 511 138]/Subtype/Widget/T(WorkersCompensation_Individual_RatingClassificationCode_A)/TU(Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only. )/Type/Annot>> endobj 521 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 522 0 obj <> endobj 523 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 518 126 590 138]/Subtype/Widget/T(WorkersCompensation_Individual_RemunerationAmount_A)/TU(Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws.\n\n\(Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals\). )/Type/Annot>> endobj 524 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 525 0 obj <> endobj 526 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 18 102 36 114]/Subtype/Widget/T(WorkersCompensation_Individual_StateOrProvinceCode_B)/TU(Enter code: The state in which the individual's payroll developed. )/Type/Annot>> endobj 527 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 528 0 obj <> endobj 529 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 40 102 61 114]/Subtype/Widget/T(WorkersCompensation_Individual_LocationProducerIdentifier_B)/TU(Enter number: The producer assigned location number for the individual. )/Type/Annot>> endobj 530 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 531 0 obj <> endobj 532 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8392704/P 4 0 R /Rect[ 68 96 162 120]/Subtype/Widget/T(WorkersCompensation_Individual_FullName_B)/TU(Enter text: The full name of the partner or executive officer being included or excluded by the policy. )/Type/Annot>> endobj 533 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 534 0 obj <> endobj 535 0 obj <>>>/AP<>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/MaxLen 10/P 4 0 R /Q 1/Rect[ 169 102 227 114]/Subtype/Widget/T(WorkersCompensation_Individual_BirthDate_B)/TU(Enter date: The individual's birth date. )/Type/Annot>> endobj 536 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 537 0 obj <> endobj 538 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8392704/P 4 0 R /Rect[ 234 96 284 120]/Subtype/Widget/T(WorkersCompensation_Individual_TitleRelationshipCode_B)/TU(Enter code: The individual's title within the organization or relationship to the organization's owners. )/Type/Annot>> endobj 539 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 540 0 obj <> endobj 541 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 292 102 313 114]/Subtype/Widget/T(WorkersCompensation_Individual_OwnershipPercent_B)/TU(Enter percentage: The percentage of ownership the individual has in the organization, if applicable. )/Type/Annot>> endobj 542 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 543 0 obj <> endobj 544 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8392704/P 4 0 R /Rect[ 320 96 436 120]/Subtype/Widget/T(WorkersCompensation_Individual_DutiesDescription_B)/TU(Enter text: The brief description of the duties of the individual. )/Type/Annot>> endobj 545 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 546 0 obj <> endobj 547 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 443 102 464 114]/Subtype/Widget/T(WorkersCompensation_Individual_IncludedExcludedCode_B)/TU(Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. )/Type/Annot>> endobj 548 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 549 0 obj <> endobj 550 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 472 102 511 114]/Subtype/Widget/T(WorkersCompensation_Individual_RatingClassificationCode_B)/TU(Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only. )/Type/Annot>> endobj 551 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 552 0 obj <> endobj 553 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 518 102 590 114]/Subtype/Widget/T(WorkersCompensation_Individual_RemunerationAmount_B)/TU(Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws.\n\n\(Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals\). )/Type/Annot>> endobj 554 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 555 0 obj <> endobj 556 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 18 78 36 90]/Subtype/Widget/T(WorkersCompensation_Individual_StateOrProvinceCode_C)/TU(Enter code: The state in which the individual's payroll developed. )/Type/Annot>> endobj 557 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 558 0 obj <> endobj 559 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 40 78 61 90]/Subtype/Widget/T(WorkersCompensation_Individual_LocationProducerIdentifier_C)/TU(Enter number: The producer assigned location number for the individual. )/Type/Annot>> endobj 560 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 561 0 obj <> endobj 562 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8392704/P 4 0 R /Rect[ 68 72 162 96]/Subtype/Widget/T(WorkersCompensation_Individual_FullName_C)/TU(Enter text: The full name of the partner or executive officer being included or excluded by the policy. )/Type/Annot>> endobj 563 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 564 0 obj <> endobj 565 0 obj <>>>/AP<>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/MaxLen 10/P 4 0 R /Q 1/Rect[ 169 78 227 90]/Subtype/Widget/T(WorkersCompensation_Individual_BirthDate_C)/TU(Enter date: The individual's birth date. )/Type/Annot>> endobj 566 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 567 0 obj <> endobj 568 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8392704/P 4 0 R /Rect[ 234 72 284 96]/Subtype/Widget/T(WorkersCompensation_Individual_TitleRelationshipCode_C)/TU(Enter code: The individual's title within the organization or relationship to the organization's owners. )/Type/Annot>> endobj 569 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 570 0 obj <> endobj 571 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 292 78 313 90]/Subtype/Widget/T(WorkersCompensation_Individual_OwnershipPercent_C)/TU(Enter percentage: The percentage of ownership the individual has in the organization, if applicable. )/Type/Annot>> endobj 572 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 573 0 obj <> endobj 574 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8392704/P 4 0 R /Rect[ 320 72 436 96]/Subtype/Widget/T(WorkersCompensation_Individual_DutiesDescription_C)/TU(Enter text: The brief description of the duties of the individual. )/Type/Annot>> endobj 575 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 576 0 obj <> endobj 577 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 443 78 464 90]/Subtype/Widget/T(WorkersCompensation_Individual_IncludedExcludedCode_C)/TU(Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. )/Type/Annot>> endobj 578 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 579 0 obj <> endobj 580 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 472 78 511 90]/Subtype/Widget/T(WorkersCompensation_Individual_RatingClassificationCode_C)/TU(Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only. )/Type/Annot>> endobj 581 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 582 0 obj <> endobj 583 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 518 78 590 90]/Subtype/Widget/T(WorkersCompensation_Individual_RemunerationAmount_C)/TU(Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws.\n\n\(Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals\). )/Type/Annot>> endobj 584 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 585 0 obj <> endobj 586 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 18 54 36 66]/Subtype/Widget/T(WorkersCompensation_Individual_StateOrProvinceCode_D)/TU(Enter code: The state in which the individual's payroll developed. )/Type/Annot>> endobj 587 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 588 0 obj <> endobj 589 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Q 1/Rect[ 40 54 61 66]/Subtype/Widget/T(WorkersCompensation_Individual_LocationProducerIdentifier_D)/TU(Enter number: The producer assigned location number for the individual. )/Type/Annot>> endobj 590 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 591 0 obj <> endobj 592 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8392704/P 4 0 R /Rect[ 68 48 162 72]/Subtype/Widget/T(WorkersCompensation_Individual_FullName_D)/TU(Enter text: The full name of the partner or executive officer being included or excluded by the policy. )/Type/Annot>> endobj 593 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 594 0 obj <> endobj 595 0 obj <>>>/AP<>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/MaxLen 10/P 4 0 R /Q 1/Rect[ 169 54 227 66]/Subtype/Widget/T(WorkersCompensation_Individual_BirthDate_D)/TU(Enter date: The individual's birth date. )/Type/Annot>> endobj 596 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 597 0 obj <> endobj 598 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8392704/P 4 0 R /Rect[ 234 48 284 72]/Subtype/Widget/T(WorkersCompensation_Individual_TitleRelationshipCode_D)/TU(Enter code: The individual's title within the organization or relationship to the organization's owners. )/Type/Annot>> endobj 599 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 600 0 obj <> endobj 601 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 292 54 313 66]/Subtype/Widget/T(WorkersCompensation_Individual_OwnershipPercent_D)/TU(Enter percentage: The percentage of ownership the individual has in the organization, if applicable. )/Type/Annot>> endobj 602 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 603 0 obj <> endobj 604 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8392704/P 4 0 R /Rect[ 320 48 436 72]/Subtype/Widget/T(WorkersCompensation_Individual_DutiesDescription_D)/TU(Enter text: The brief description of the duties of the individual. )/Type/Annot>> endobj 605 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 606 0 obj <> endobj 607 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 443 54 464 66]/Subtype/Widget/T(WorkersCompensation_Individual_IncludedExcludedCode_D)/TU(Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages. )/Type/Annot>> endobj 608 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 609 0 obj <> endobj 610 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 472 54 511 66]/Subtype/Widget/T(WorkersCompensation_Individual_RatingClassificationCode_D)/TU(Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only. )/Type/Annot>> endobj 611 0 obj <>/Subtype/Form/Type/XObject>>stream x+ endstream endobj 612 0 obj <> endobj 613 0 obj <>/DA(/F2 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/P 4 0 R /Rect[ 518 54 590 66]/Subtype/Widget/T(WorkersCompensation_Individual_RemunerationAmount_D)/TU(Enter amount: The estimated annual remuneration for individual listed. 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