PureEdge 4/12/2003 76B9AA27-47C7-48B5-B040-D177ABEE46D6 9.51.2 ACORD 2 (2005/02) ACORD Customer Service: Telephone: (845) 620-1700 ex. 506 Address: New York Office (World Headquarters) Two Blue Hill Plaza 3rd Floor PO Box 1529 Pearl River, NY 10965-8529 USA Auto Fillable.xfd 1 Times New Roman 10 plain 0 on T-EBQV-N9WQ-9NR6-Z9T6-KBKC off off off off off off off off off off off off off off off 2005/02 [custom:DEFAULT_MAP][custom:PAGE1][custom:CB1] PAGE1.CB1.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CB2] PAGE1.CB2.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK3] PAGE1.CHECK3.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK4] PAGE1.CHECK4.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK5] PAGE1.CHECK5.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK6] PAGE1.CHECK6.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK9] PAGE1.CHECK9.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK10] PAGE1.CHECK10.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK11] 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[custom:DEFAULT_MAP][custom:PAGE1][custom:changeVerFIELD] PAGE1.changeVerFIELD.value etb TRADITIONAL letter 120 8.5;11.0 E57445F8-2867-4833-9C5B-4FC3177A7CF9 239 239 239 255 255 255 DATE absolute 816 34 extent 146 2 absolute 960 34 extent 2 201 absolute 0 75 extent 2 160 absolute 816 34 extent 2 41 2 absolute 814 195 extent 16 16 Check box CB1 off Arial 18 plain FIELD4 CB2 absolute 814 215 extent 16 16 Check box CB2 off Arial 18 plain CB1 CHECK1 absolute 563 237 extent 16 16 Check box CB2 off Arial 18 plain BUSINESS_PHONE NAME_AND_ADDRESS HELP23 absolute 70 598 extent 16 16 Check box CB2 off Arial 18 plain COLLISION_DED CHECK5 HELP44 absolute 166 598 extent 16 16 Check box CB2 off Arial 18 plain CHECK4 EF7 HELP45 absolute 7 738 extent 16 16 Check box CB2 off Arial 18 plain BUSINESS_PHONE3 FIELD17 absolute 274 838 extent 16 16 Check box CB2 off Arial 18 plain OTHER_INSURANCE_ON_VEHICLE CHECK10 absolute 334 838 extent 16 16 Check box CB2 off Arial 18 plain CHECK9 FIELD21 absolute 430 879 extent 16 16 Check box CB2 off Arial 18 plain FIELD21 CHECK12 absolute 7 959 extent 16 16 Check box CB2 off Arial 18 plain BUSINESS_PHONE5 FIELD23 absolute 491 879 extent 16 16 Check box CB2 off Arial 18 plain CHECK11 COMPANY_OR_AGENCY_NAME absolute 850 779 extent 16 16 Check box CB2 off Arial 18 plain FIELD18 CHECK8 absolute 910 779 extent 16 16 Check box CB2 off Arial 18 plain CHECK7 FIELD19 absolute 818 53 extent 140 24 0 Field DATE wordwrap fixed Arial 10 plain date optional MM/DD/YYYY DATE EF2 HELP1 center absolute 557 76 extent 132 21 0 Field DATE wordwrap fixed Arial 8 plain EF1 MISCELLANEOUS_INFO HELP9 string optional MM/DD/YYYY absolute 151 76 extent 225 21 0 Field PHONE wordwrap fixed Arial 8 plain EF2 HELP2 FAX absolute 691 93 0 Field MISCELLANEOUS_INFO wordwrap fixed Arial 10 FIELD1 POLICY_NUMBER HELP10 26 2 0 Field EF1 wordwrap fixed Arial 9 plain AGENCY_CUSTOMER_ID FIELD1 HELP8 absolute 381 96 extent 308 40 0 Field EF2 wordwrap fixed Arial 9 plain DATE PHONE HELP4 absolute 2 97 extent 374 74 absolute 0 172 extent 379 1 0 Field Sub_Code wordwrap fixed Arial 7 plain absolute 242 173 extent 134 21 FAX FIELD2 HELP115 absolute 50 173 extent 135 21 0 Field FAX wordwrap fixed Arial 7 plain string optional PHONE FIELD28 HELP114 absolute 380 153 extent 153 24 0 Field POLICY_NUMBER wordwrap fixed Arial 10 plain MISCELLANEOUS_INFO POLICY_TYPE HELP11 absolute 536 153 extent 154 24 0 Field POLICY_TYPE wordwrap fixed Arial 10 plain POLICY_NUMBER REFERENCE_NUMBER HELP12 absolute 691 153 extent 190 24 0 Field REFERENCE_NUMBER wordwrap fixed Arial 10 plain POLICY_TYPE CAT HELP13 absolute 883 153 extent 75 24 0 Field CAT wordwrap fixed Arial 10 plain REFERENCE_NUMBER EFFECTIVE_DATE HELP14 absolute 380 203 extent 123 24 0 Field EFFECTIVE_DATE wordwrap fixed Arial 10 plain date optional MM/DD/YYYY CAT EXPIRATION_DATE HELP15 center absolute 505 203 extent 124 24 0 Field EXPIRATION_DATE wordwrap fixed Arial 10 plain date optional MM/DD/YYYY EFFECTIVE_DATE DATE_OF_ACCIDENT_AND_TIME HELP16 center absolute 631 203 extent 106 24 0 Field DATE_OF_ACCIDENT_AND_TIME wordwrap fixed Arial 10 plain date optional MM/DD/YYYY EXPIRATION_DATE FIELD4 HELP17 center absolute 741 203 extent 66 24 0 Field DATE_OF_ACCIDENT_AND_TIME wordwrap fixed Arial 10 plain string optional DATE_OF_ACCIDENT_AND_TIME CB1 absolute 79 215 extent 297 21 0 Field AGENCY_CUSTOMER_ID wordwrap fixed Arial 8 plain FIELD3 EF1 HELP7 absolute 45 195 extent 140 21 0 Field AGENCY_CUSTOMER_ID wordwrap fixed Arial 8 plain FIELD28 FIELD3 HELP5 absolute 251 195 extent 125 21 0 Field AGENCY_CUSTOMER_ID wordwrap fixed Arial 8 plain FIELD2 AGENCY_CUSTOMER_ID HELP6 absolute 416 271 0 Field NAME_AND_ADDRESS wordwrap fixed Arial 10 plain CHECK3 RESIDENCE_PHONE2 HELP24 41 3 0 Field WHERE_TO_CONTACT wordwrap fixed Arial 10 BUSINESS_PHONE2 WHEN_TO_CONTACT HELP27 absolute 835 271 extent 123 44 0 Field NAME_AND_ADDRESS2 wordwrap fixed Arial 9 plain CHECK2 EF6 HELP19 absolute 2 279 extent 409 57 absolute 296 254 extent 115 22 0 Field EF6 wordwrap Arial 8 plain NAME_AND_ADDRESS2 RESIDENCE_PHONE HELP20 fixed 0 Field WHEN_TO_CONTACT wordwrap fixed Arial 10 WHERE_TO_CONTACT FIELD5 HELP28 absolute 835 333 extent 123 44 absolute 2 353 extent 195 24 0 Field RESIDENCE_PHONE wordwrap fixed Arial 10 plain EF6 BUSINESS_PHONE HELP21 string optional absolute 199 353 extent 213 24 0 Field BUSINESS_PHONE wordwrap fixed Arial 10 plain RESIDENCE_PHONE CHECK3 HELP22 absolute 416 353 extent 201 24 0 Field RESIDENCE_PHONE2 wordwrap fixed Arial 10 plain NAME_AND_ADDRESS BUSINESS_PHONE2 HELP25 string optional absolute 619 353 extent 214 24 0 Field BUSINESS_PHONE2 wordwrap fixed Arial 10 plain RESIDENCE_PHONE2 WHERE_TO_CONTACT HELP26 absolute 781 411 extent 177 24 0 Field VIOLATIONS_CITATIONS wordwrap fixed Arial 10 plain FIELD7 FIELD8 HELP32 absolute 114 396 0 Field VIOLATIONS_CITATIONS wordwrap fixed Arial 9 plain WHEN_TO_CONTACT FIELD6 HELP29 46 2 absolute 115 438 0 Field VIOLATIONS_CITATIONS wordwrap fixed Arial 9 plain VIOLATIONS_CITATIONS FIELD9 HELP33 93 3 absolute 612 395 extent 166 22 0 Field VIOLATIONS_CITATIONS wordwrap fixed Arial 8 plain FIELD5 FIELD7 HELP30 absolute 613 416 extent 166 22 0 Field VIOLATIONS_CITATIONS wordwrap fixed Arial 8 plain FIELD6 VIOLATIONS_CITATIONS HELP31 absolute 241 535 extent 118 22 0 Field PROPERTY_DAMAGE wordwrap fixed Arial 9 plain FIELD10 SINGLE_LIMIT HELP37 absolute 2 535 extent 118 22 0 Field PROPERTY_DAMAGE wordwrap fixed Arial 9 plain FIELD8 FIELD10 HELP35 absolute 121 535 extent 118 22 0 Field PROPERTY_DAMAGE wordwrap fixed Arial 9 plain FIELD9 PROPERTY_DAMAGE HELP36 absolute 361 535 extent 118 22 0 Field SINGLE_LIMIT wordwrap fixed Arial 9 plain PROPERTY_DAMAGE MEDICAL_PAYMENT HELP38 absolute 481 535 extent 118 22 0 Field MEDICAL_PAYMENT wordwrap fixed Arial 9 plain SINGLE_LIMIT OTC_DEDUCTIBLE HELP39 absolute 601 535 extent 118 22 0 Field OTC_DEDUCTIBLE wordwrap fixed Arial 9 plain MEDICAL_PAYMENT OTHER_COVERAGE_DEDUCTIBLES HELP40 absolute 721 539 extent 236 55 0 Field OTHER_COVERAGE_DEDUCTIBLES wordwrap fixed Arial 8 plain OTC_DEDUCTIBLE LOSS_PAYEE HELP41 absolute 2 571 extent 597 23 0 Field LOSS_PAYEE wordwrap fixed Arial 9 plain OTHER_COVERAGE_DEDUCTIBLES COLLISION_DED HELP42 absolute 601 571 extent 118 23 0 Field COLLISION_DED wordwrap fixed Arial 9 plain LOSS_PAYEE CHECK4 HELP43 absolute 298 596 extent 180 21 0 Field EF7 wordwrap fixed Arial 8 plain CHECK5 EF8 HELP46 absolute 525 596 extent 110 21 0 Field EF8 wordwrap fixed Arial 8 plain EF7 FIELD11 HELP47 absolute 676 596 extent 108 21 0 Field EF8 wordwrap fixed Arial 8 plain EF8 FIELD12 absolute 845 596 extent 82 21 0 Field EF8 wordwrap fixed Arial 8 plain FIELD11 VEH absolute 458 636 extent 320 21 0 Field BODY_TYPE wordwrap fixed Arial 8 plain FIELD14 FIELD15 HELP53 absolute 459 656 extent 320 21 0 Field BODY_TYPE wordwrap fixed Arial 8 plain BODY_TYPE PLATE_NUMBER HELP54 absolute 143 636 extent 277 21 0 Field BODY_TYPE wordwrap fixed Arial 8 plain YEAR FIELD14 HELP51 absolute 152 656 extent 269 21 0 Field BODY_TYPE wordwrap fixed Arial 8 plain FIELD13 BODY_TYPE HELP52 0 Field BODY_TYPE wordwrap fixed Arial 9 plain STATE RESIDENCE_PHONE3 HELP57 absolute 72 676 extent 577 40 absolute 112 716 0 Field BODY_TYPE wordwrap fixed Arial 9 plain CHECK6 RESIDENCE_PHONE4 HELP60 59 2 absolute 2 651 extent 51 24 0 Field VEH wordwrap fixed Arial 10 plain FIELD12 YEAR HELP49 absolute 55 651 extent 45 24 0 Field YEAR wordwrap fixed Arial 10 plain VEH FIELD13 HELP50 string optional absolute 781 651 extent 123 23 0 Field PLATE_NUMBER wordwrap fixed Arial 9 plain FIELD15 STATE HELP55 absolute 907 651 extent 51 23 0 Field STATE wordwrap fixed Arial 9 plain PLATE_NUMBER FIELD16 HELP56 string optional 0 2 absolute 754 676 extent 205 21 0 Field RESIDENCE_PHONE3 wordwrap fixed Arial 8 plain FIELD16 BUSINESS_PHONE3 HELP58 string optional absolute 749 696 extent 210 21 0 Field BUSINESS_PHONE3 wordwrap fixed Arial 8 plain RESIDENCE_PHONE3 CHECK6 HELP59 string optional absolute 754 716 extent 205 21 0 Field RESIDENCE_PHONE4 wordwrap fixed Arial 8 plain FIELD17 BUSINESS_PHONE4 HELP61 string optional absolute 748 736 extent 211 21 0 Field BUSINESS_PHONE4 wordwrap fixed Arial 8 plain RESIDENCE_PHONE4 RELATION_TO_INSURED HELP62 string optional absolute 175 773 extent 106 24 0 Field DATE_OF_BIRTH wordwrap fixed Arial 10 plain RELATION_TO_INSURED DRIVERS_LICENSE_NUMBER HELP64 date optional MM/DD/YYYY center absolute 60 796 0 Field DATE_OF_BIRTH wordwrap fixed Arial 9 plain CHECK8 ESTIMATE_AMOUNT HELP69 20 2 absolute 118 856 0 Field DATE_OF_BIRTH wordwrap fixed Arial 9 plain CHECK10 CHECK11 HELP75 33 2 absolute 64 897 0 Field DATE_OF_BIRTH wordwrap fixed Arial 9 plain FIELD24 RESIDENCE_PHONE5 HELP78 64 2 absolute 118 936 0 Field DATE_OF_BIRTH wordwrap fixed Arial 9 plain CHECK13 RESIDENCE_PHONE6 HELP81 58 2 absolute 283 773 extent 304 24 0 Field DRIVERS_LICENSE_NUMBER wordwrap fixed Arial 10 plain DATE_OF_BIRTH STATE2 HELP65 absolute 439 797 extent 215 39 0 Field DRIVERS_LICENSE_NUMBER wordwrap fixed Arial 8 plain ESTIMATE_AMOUNT WHEN_CAN_VEH_BE_SEEN HELP71 absolute 589 773 extent 34 24 0 Field STATE2 wordwrap fixed Arial 10 plain DRIVERS_LICENSE_NUMBER FIELD18 HELP66 string optional 0 2 absolute 684 773 extent 157 24 0 Field STATE2 wordwrap fixed Arial 10 plain STATE2 CHECK7 HELP67 absolute 2 776 extent 171 21 0 Field RELATION_TO_INSURED wordwrap fixed Arial 8 plain BUSINESS_PHONE4 DATE_OF_BIRTH HELP63 absolute 253 811 extent 118 23 0 Field ESTIMATE_AMOUNT wordwrap fixed Arial 9 plain FIELD19 FIELD20 HELP70 dollar comma_delimit optional absolute 655 812 extent 136 24 0 Field WHEN_CAN_VEH_BE_SEEN wordwrap fixed Arial 10 plain FIELD20 OTHER_INSURANCE_ON_VEHICLE HELP72 absolute 793 812 extent 165 24 0 Field OTHER_INSURANCE_ON_VEHICLE wordwrap fixed Arial 10 plain WHEN_CAN_VEH_BE_SEEN CHECK9 HELP73 absolute 636 856 extent 324 21 0 Field COMPANY_OR_AGENCY_NAME wordwrap fixed Arial 8 plain CHECK12 FIELD24 HELP77 absolute 616 876 extent 344 21 0 Field COMPANY_OR_AGENCY_NAME wordwrap fixed Arial 8 plain COMPANY_OR_AGENCY_NAME FIELD22 HELP107 absolute 754 896 extent 205 21 0 Field RESIDENCE_PHONE5 wordwrap fixed Arial 8 plain FIELD22 BUSINESS_PHONE5 string optional HELP113 absolute 749 916 extent 210 21 0 Field BUSINESS_PHONE5 wordwrap fixed Arial 8 plain RESIDENCE_PHONE5 CHECK13 HELP80 string optional absolute 754 936 extent 205 21 0 Field RESIDENCE_PHONE6 wordwrap fixed Arial 8 plain FIELD23 BUSINESS_PHONE6 HELP82 string optional absolute 749 956 extent 210 21 0 Field BUSINESS_PHONE6 wordwrap fixed Arial 8 plain RESIDENCE_PHONE6 FIELD25 HELP83 string optional absolute 253 993 extent 118 24 0 Field ESTIMATE_AMOUNT2 wordwrap fixed Arial 10 plain FIELD25 FIELD26 HELP85 dollar comma_delimit optional absolute 62 976 0 Field ESTIMATE_AMOUNT2 wordwrap fixed Arial 9 plain BUSINESS_PHONE6 ESTIMATE_AMOUNT2 HELP84 20 2 absolute 449 976 0 Field ESTIMATE_AMOUNT2 wordwrap fixed Arial 9 plain ESTIMATE_AMOUNT2 EF17 HELP86 56 2 absolute 2 1056 extent 447 21 0 Field EF17 wordwrap fixed Arial 8 plain FIELD26 EF18 HELP88 absolute 451 1056 extent 178 21 0 Field EF18 wordwrap fixed Arial 8 plain EF17 EF19 HELP89 string optional absolute 636 1057 extent 22 21 Field EF19 Arial 8 plain EF18 EF22 HELP90 center absolute 703 1056 extent 46 21 0 Field EF20 wordwrap fixed Arial 8 plain EF23 EF21 HELP93 string optional absolute 751 1056 extent 207 21 0 Field EF21 wordwrap fixed Arial 8 plain EF20 EF24 HELP94 absolute 660 1057 extent 22 21 Field EF22 Arial 8 plain EF19 EF23 HELP91 center absolute 684 1057 extent 22 21 Field EF23 Arial 8 plain EF22 EF20 HELP92 center absolute 2 1076 extent 447 21 0 Field EF24 wordwrap fixed Arial 8 plain EF21 EF25 HELP108 absolute 451 1076 extent 178 21 0 Field EF25 wordwrap fixed Arial 8 plain EF24 EF26 string optional HELP109 absolute 636 1077 extent 22 21 Field EF26 Arial 8 plain EF25 EF27 center absolute 660 1077 extent 22 21 Field EF27 Arial 8 plain EF26 EF28 center HELP112 absolute 684 1077 extent 22 21 Field EF28 Arial 8 plain EF27 EF29 center absolute 703 1076 extent 46 21 0 Field EF29 wordwrap fixed Arial 8 plain EF28 EF30 string optional absolute 751 1076 extent 207 21 0 Field EF30 wordwrap fixed Arial 8 plain EF29 EF31 absolute 2 1136 extent 447 21 0 Field EF31 wordwrap fixed Arial 8 plain EF30 EF32 HELP96 absolute 451 1136 extent 178 21 0 Field EF32 wordwrap fixed Arial 8 plain EF31 EF34 HELP97 string optional absolute 679 1136 extent 279 21 0 Field EF33 wordwrap fixed Arial 8 plain EF35 EF36 HELP100 absolute 636 1137 extent 22 21 Field EF34 Arial 8 plain EF32 EF35 HELP98 center absolute 660 1137 extent 22 21 Field EF35 Arial 8 plain EF34 EF33 HELP99 center absolute 2 1155 extent 447 21 0 Field EF36 wordwrap fixed Arial 8 plain EF33 EF37 HELP111 absolute 106 1175 0 Field EF36 wordwrap fixed Arial 9 plain EF40 REPORTED_BY HELP101 94 2 absolute 451 1155 extent 178 21 0 Field EF37 wordwrap fixed Arial 8 plain EF36 EF38 string optional HELP110 absolute 636 1156 extent 22 21 Field EF38 Arial 8 plain EF37 EF39 center absolute 660 1156 extent 22 21 Field EF39 Arial 8 plain EF38 EF40 center absolute 679 1155 extent 279 21 0 Field EF40 wordwrap fixed Arial 8 plain EF39 FIELD27 absolute 2 1231 extent 177 24 0 Field REPORTED_BY wordwrap fixed Arial 10 plain FIELD27 REPORTED_TO HELP102 absolute 181 1231 extent 178 24 0 Field REPORTED_TO wordwrap fixed Arial 10 plain REPORTED_BY HELP103 F113