22/12/2003 55089858-1030-455C-871D-467C436A6231 7.27.1 Arial 10 plain 0

on

application/vnd.xfdl application/vnd.xfdl Liability Fillable.xfd 1 PureEdge 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 T-R9QV-U9BH-9LR6-Z9TV-8YHC off off off off off off off off off off off off off off off off off off off off 2005/02 [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK6] PAGE1.CHECK6.value [custom:DEFAULT_MAP][custom:PAGE1][custom:DATE] PAGE1.DATE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:PHONE] PAGE1.PHONE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD1] PAGE1.FIELD1.value [custom:DEFAULT_MAP][custom:PAGE1][custom:DATE_OF_CLAIM] PAGE1.DATE_OF_CLAIM.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EFFECTIVE_DATE] PAGE1.EFFECTIVE_DATE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EXPIRATION_DATE] PAGE1.EXPIRATION_DATE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:RETROACTIVE_DATE] PAGE1.RETROACTIVE_DATE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF4] PAGE1.EF4.value [custom:DEFAULT_MAP][custom:PAGE1][custom:COMPANY] PAGE1.COMPANY.value [custom:DEFAULT_MAP][custom:PAGE1][custom:MISCELLANEOUS_INFO] PAGE1.MISCELLANEOUS_INFO.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF7] PAGE1.EF7.value [custom:DEFAULT_MAP][custom:PAGE1][custom:POLICY_NUMBER] PAGE1.POLICY_NUMBER.value [custom:DEFAULT_MAP][custom:PAGE1][custom:REFERENCE_NUMBER] PAGE1.REFERENCE_NUMBER.value [custom:DEFAULT_MAP][custom:PAGE1][custom:AGENCY_CUSTOMER_ID] PAGE1.AGENCY_CUSTOMER_ID.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD2] PAGE1.FIELD2.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD3] PAGE1.FIELD3.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD7] PAGE1.FIELD7.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD8] PAGE1.FIELD8.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD9] PAGE1.FIELD9.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD10] PAGE1.FIELD10.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD11] PAGE1.FIELD11.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD12] PAGE1.FIELD12.value [custom:DEFAULT_MAP][custom:PAGE1][custom:NAME_AND_ADDRESS] PAGE1.NAME_AND_ADDRESS.value [custom:DEFAULT_MAP][custom:PAGE1][custom:WHERE_TO_CONTACT] PAGE1.WHERE_TO_CONTACT.value [custom:DEFAULT_MAP][custom:PAGE1][custom:NAME_AND_ADDRESS2] PAGE1.NAME_AND_ADDRESS2.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF9] PAGE1.EF9.value [custom:DEFAULT_MAP][custom:PAGE1][custom:WHEN_TO_CONTACT] PAGE1.WHEN_TO_CONTACT.value [custom:DEFAULT_MAP][custom:PAGE1][custom:RESIDENCE_PHONE] PAGE1.RESIDENCE_PHONE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:BUSINESS_PHONE] PAGE1.BUSINESS_PHONE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:RESIDENCE_PHONE2] PAGE1.RESIDENCE_PHONE2.value [custom:DEFAULT_MAP][custom:PAGE1][custom:BUSINESS_PHONE2] PAGE1.BUSINESS_PHONE2.value [custom:DEFAULT_MAP][custom:PAGE1][custom:AUTHORITY_CONTACTED] PAGE1.AUTHORITY_CONTACTED.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD4] PAGE1.FIELD4.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD6] PAGE1.FIELD6.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD5] PAGE1.FIELD5.value [custom:DEFAULT_MAP][custom:PAGE1][custom:GENERAL_AGGREGATE] PAGE1.GENERAL_AGGREGATE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:PROD_COMP_OP_AGG] PAGE1.PROD_COMP_OP_AGG.value [custom:DEFAULT_MAP][custom:PAGE1][custom:PERS_ADV_INJ] PAGE1.PERS_ADV_INJ.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EACH_OCCURRENCE] PAGE1.EACH_OCCURRENCE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIRE_DAMAGE] PAGE1.FIRE_DAMAGE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:MEDICAL_EXPENSE] PAGE1.MEDICAL_EXPENSE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:DEDUCTIBLE] PAGE1.DEDUCTIBLE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:TYPE_OF_PREMISES] PAGE1.TYPE_OF_PREMISES.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD13] PAGE1.FIELD13.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD14] PAGE1.FIELD14.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD18] PAGE1.FIELD18.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD17] PAGE1.FIELD17.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD16] PAGE1.FIELD16.value [custom:DEFAULT_MAP][custom:PAGE1][custom:OWNERS_PHONE] PAGE1.OWNERS_PHONE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:TYPE_OF_PRODUCT] PAGE1.TYPE_OF_PRODUCT.value [custom:DEFAULT_MAP][custom:PAGE1][custom:MANUFACT_PHONE] PAGE1.MANUFACT_PHONE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD15] PAGE1.FIELD15.value [custom:DEFAULT_MAP][custom:PAGE1][custom:PHONE2] PAGE1.PHONE2.value [custom:DEFAULT_MAP][custom:PAGE1][custom:AGE] PAGE1.AGE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:SEX] PAGE1.SEX.value [custom:DEFAULT_MAP][custom:PAGE1][custom:OCCUPATION] PAGE1.OCCUPATION.value [custom:DEFAULT_MAP][custom:PAGE1][custom:PHONE3] PAGE1.PHONE3.value [custom:DEFAULT_MAP][custom:PAGE1][custom:WHERE_TAKEN] PAGE1.WHERE_TAKEN.value [custom:DEFAULT_MAP][custom:PAGE1][custom:WHAT_WAS_INJURED_DOING] PAGE1.WHAT_WAS_INJURED_DOING.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF18] PAGE1.EF18.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD19] PAGE1.FIELD19.value [custom:DEFAULT_MAP][custom:PAGE1][custom:ESTIMATE_AMOUNT] PAGE1.ESTIMATE_AMOUNT.value [custom:DEFAULT_MAP][custom:PAGE1][custom:WHEN_CAN_PROPERTY_BE_SEEN] PAGE1.WHEN_CAN_PROPERTY_BE_SEEN.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD20] PAGE1.FIELD20.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF19] PAGE1.EF19.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF20] PAGE1.EF20.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF21] PAGE1.EF21.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF22] PAGE1.EF22.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF23] PAGE1.EF23.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF24] PAGE1.EF24.value [custom:DEFAULT_MAP][custom:PAGE1][custom:REMARKS] PAGE1.REMARKS.value [custom:DEFAULT_MAP][custom:PAGE1][custom:REPORTED_BY] PAGE1.REPORTED_BY.value [custom:DEFAULT_MAP][custom:PAGE1][custom:REPORTED_TO] PAGE1.REPORTED_TO.value [custom:DEFAULT_MAP][custom:PAGE1][custom:SIGNATURE_OF_INSURED] PAGE1.SIGNATURE_OF_INSURED.value [custom:DEFAULT_MAP][custom:PAGE1][custom:SIGNATURE_OF_PRODUCER] PAGE1.SIGNATURE_OF_PRODUCER.value [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:CHECK1] PAGE1.CHECK1.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CB3] PAGE1.CB3.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK2] PAGE1.CHECK2.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK3] PAGE1.CHECK3.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CB4] PAGE1.CB4.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK15] PAGE1.CHECK15.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK7] PAGE1.CHECK7.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK9] PAGE1.CHECK9.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK12] PAGE1.CHECK12.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK10] PAGE1.CHECK10.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK11] PAGE1.CHECK11.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK8] PAGE1.CHECK8.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CB5] PAGE1.CB5.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:CHECK13] PAGE1.CHECK13.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK14] PAGE1.CHECK14.value [custom:DEFAULT_MAP][custom:PAGE1][custom:changeVerFIELD] PAGE1.changeVerFIELD.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD28] PAGE1.FIELD28.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FAX] PAGE1.FAX.value [custom:DEFAULT_MAP][custom:PAGE1][custom:DATE_OF_OCCURRENCE_AND_TIME] PAGE1.DATE_OF_OCCURRENCE_AND_TIME.value off TRADITIONAL letter 120 8.5;11.0 0CCB73A3-9951-4DD9-BE9F-9068F93977B4 239 239 239 255 255 255 DATE absolute 563 234 extent 21 21 Check box CB3 off Arial 18 plain HELP25 BUSINESS_PHONE NAME_AND_ADDRESS absolute 7 18 LOGODATA null absolute 819 49 extent 140 25 0 Field DATE Arial 10 plain wordwrap fixed date optional MM/DD/YYYY HELP2 DATE EF4 center absolute 153 74 extent 224 21 0 Field PHONE Arial 8 plain wordwrap fixed HELP4 EF4 FAX within TOOLBAR absolute 1 1 extent 1 1 0 239 239 239 255 255 255 cancel 1 1 absolute 632 90 extent 70 25 0 Field DATE_OF_OCCURRENCE_AND_TIME Arial 10 plain wordwrap fixed DATE_OF_OCCURRENCE_AND_TIME CB1 string optional absolute 752 90 extent 106 25 0 Field DATE_OF_CLAIM Arial 10 plain wordwrap fixed date optional MM/DD/YYYY HELP10 CB3 CHECK2 center absolute 381 130 extent 105 25 0 Field EFFECTIVE_DATE Arial 10 plain wordwrap fixed date optional MM/DD/YYYY HELP12 CHECK3 EXPIRATION_DATE center absolute 488 130 extent 106 25 0 Field EXPIRATION_DATE Arial 10 plain wordwrap fixed date optional MM/DD/YYYY HELP13 EFFECTIVE_DATE CHECK4 center absolute 842 130 extent 117 25 0 Field RETROACTIVE_DATE Arial 10 plain wordwrap fixed date optional MM/DD/YYYY HELP15 CHECK5 COMPANY center absolute 3 94 extent 374 77 0 Field EF4 wordwrap fixed HELP3 DATE PHONE absolute 381 174 extent 309 21 0 Field COMPANY Arial 8 plain wordwrap fixed HELP16 RETROACTIVE_DATE EF7 absolute 692 170 extent 267 25 0 Field MISCELLANEOUS_INFO Arial 10 plain wordwrap fixed HELP18 EF7 POLICY_NUMBER absolute 554 154 extent 136 21 0 Field EF7 Arial 8 plain wordwrap fixed HELP17 COMPANY MISCELLANEOUS_INFO absolute 381 210 extent 309 25 0 Field POLICY_NUMBER Arial 10 plain wordwrap fixed HELP19 MISCELLANEOUS_INFO REFERENCE_NUMBER absolute 692 210 extent 267 25 0 Field REFERENCE_NUMBER Arial 10 plain wordwrap fixed HELP20 POLICY_NUMBER NAME_AND_ADDRESS2 absolute 79 214 extent 298 21 0 Field AGENCY_CUSTOMER_ID Arial 8 plain wordwrap fixed HELP7 FIELD3 CHECK1 absolute 40 194 extent 147 21 0 Field AGENCY_CUSTOMER_ID Arial 8 plain wordwrap fixed HELP5 FIELD28 FIELD3 absolute 251 194 extent 126 21 0 Field AGENCY_CUSTOMER_ID Arial 8 plain wordwrap fixed HELP6 FIELD2 AGENCY_CUSTOMER_ID absolute 296 634 extent 185 21 0 Field AGENCY_CUSTOMER_ID Arial 8 plain wordwrap fixed HELP39 CHECK8 FIELD8 absolute 526 634 extent 115 21 0 Field AGENCY_CUSTOMER_ID Arial 8 plain wordwrap fixed HELP40 FIELD7 FIELD9 absolute 676 634 extent 107 21 0 Field AGENCY_CUSTOMER_ID Arial 8 plain wordwrap fixed FIELD8 FIELD10 absolute 848 634 extent 79 21 0 Field AGENCY_CUSTOMER_ID Arial 8 plain wordwrap fixed FIELD9 CHECK9 absolute 390 675 extent 223 21 0 Field AGENCY_CUSTOMER_ID Arial 8 plain wordwrap fixed off CHECK11 TYPE_OF_PREMISES absolute 439 755 extent 174 21 0 Field AGENCY_CUSTOMER_ID Arial 8 plain wordwrap fixed off CHECK14 TYPE_OF_PRODUCT absolute 417 275 extent 417 101 0 Field NAME_AND_ADDRESS wordwrap fixed HELP26 CHECK6 RESIDENCE_PHONE2 absolute 836 270 extent 118 65 0 Field WHERE_TO_CONTACT wordwrap fixed HELP29 BUSINESS_PHONE2 WHEN_TO_CONTACT absolute 3 275 extent 410 101 0 Field NAME_AND_ADDRESS2 wordwrap fixed HELP21 REFERENCE_NUMBER EF9 absolute 297 255 extent 116 21 0 Field EF9 wordwrap fixed Arial 8 plain HELP22 NAME_AND_ADDRESS2 RESIDENCE_PHONE absolute 836 349 extent 118 65 0 Field WHEN_TO_CONTACT wordwrap fixed HELP30 WHERE_TO_CONTACT FIELD4 absolute 3 390 extent 195 25 0 Field RESIDENCE_PHONE Arial 10 plain wordwrap fixed HELP23 EF9 BUSINESS_PHONE string optional absolute 200 390 extent 213 25 0 Field BUSINESS_PHONE Arial 10 plain wordwrap fixed HELP24 RESIDENCE_PHONE CHECK6 string optional absolute 417 390 extent 201 25 0 Field RESIDENCE_PHONE2 Arial 10 plain wordwrap fixed HELP27 NAME_AND_ADDRESS BUSINESS_PHONE2 string optional absolute 620 390 extent 214 25 0 Field BUSINESS_PHONE2 Arial 10 plain wordwrap fixed HELP28 RESIDENCE_PHONE2 WHERE_TO_CONTACT string optional absolute 752 451 extent 207 25 0 Field AUTHORITY_CONTACTED Arial 10 plain wordwrap fixed HELP32 FIELD4 FIELD5 absolute 113 436 extent 636 41 0 Field AUTHORITY_CONTACTED Arial 9 plain wordwrap fixed HELP31 WHEN_TO_CONTACT AUTHORITY_CONTACTED absolute 115 570 extent 844 25 0 Field AUTHORITY_CONTACTED Arial 10 plain wordwrap fixed HELP35 FIELD5 GENERAL_AGGREGATE absolute 113 478 extent 845 59 0 Field AUTHORITY_CONTACTED Arial 9 plain wordwrap fixed HELP33 AUTHORITY_CONTACTED FIELD6 absolute 3 609 extent 129 25 0 Field GENERAL_AGGREGATE Arial 10 plain wordwrap fixed HELP36 FIELD6 PROD_COMP_OP_AGG absolute 134 609 extent 130 25 0 Field PROD_COMP_OP_AGG Arial 10 plain wordwrap fixed GENERAL_AGGREGATE PERS_ADV_INJ absolute 266 609 extent 130 25 0 Field PERS_ADV_INJ Arial 10 plain wordwrap fixed PROD_COMP_OP_AGG EACH_OCCURRENCE absolute 398 609 extent 130 25 0 Field EACH_OCCURRENCE Arial 10 plain wordwrap fixed PERS_ADV_INJ FIRE_DAMAGE absolute 530 609 extent 130 25 0 Field FIRE_DAMAGE Arial 10 plain wordwrap fixed EACH_OCCURRENCE MEDICAL_EXPENSE absolute 662 609 extent 130 25 0 Field MEDICAL_EXPENSE Arial 10 plain wordwrap fixed FIRE_DAMAGE DEDUCTIBLE absolute 794 609 extent 111 25 0 Field DEDUCTIBLE Arial 10 plain wordwrap fixed HELP41 MEDICAL_EXPENSE CB4 absolute 614 690 extent 345 45 0 Field TYPE_OF_PREMISES wordwrap fixed HELP44 FIELD11 FIELD13 absolute 91 696 extent 520 59 0 Field TYPE_OF_PREMISES wordwrap fixed HELP45 TYPE_OF_PREMISES OWNERS_PHONE Arial 9 plain absolute 100 776 extent 512 59 0 Field TYPE_OF_PREMISES wordwrap fixed HELP49 TYPE_OF_PRODUCT MANUFACT_PHONE Arial 9 plain absolute 384 956 extent 367 39 0 Field TYPE_OF_PREMISES wordwrap fixed HELP59 OCCUPATION PHONE3 Arial 8 plain absolute 88 916 extent 663 39 0 Field TYPE_OF_PREMISES wordwrap fixed HELP54 FIELD16 PHONE2 Arial 8 plain absolute 125 857 extent 833 38 0 Field TYPE_OF_PREMISES wordwrap fixed HELP52 FIELD15 FIELD17 Arial 8 plain absolute 702 734 extent 257 21 0 Field OWNERS_PHONE Arial 8 plain wordwrap fixed HELP46 FIELD13 CHECK12 string optional absolute 614 771 extent 345 45 0 Field TYPE_OF_PRODUCT wordwrap fixed HELP48 FIELD12 FIELD14 absolute 712 815 extent 247 21 0 Field MANUFACT_PHONE Arial 8 plain wordwrap fixed HELP50 FIELD14 FIELD15 string optional absolute 177 835 extent 782 21 0 Field MANUFACT_PHONE Arial 8 plain wordwrap fixed HELP51 MANUFACT_PHONE FIELD16 absolute 752 931 extent 207 25 0 Field PHONE2 Arial 10 plain wordwrap fixed HELP55 FIELD17 AGE string optional absolute 3 971 extent 45 25 0 Field AGE Arial 10 plain wordwrap fixed string optional HELP56 PHONE2 SEX absolute 50 971 extent 34 25 0 Field SEX Arial 10 plain wordwrap fixed string optional 0 1 HELP57 AGE OCCUPATION absolute 86 971 extent 226 25 0 Field OCCUPATION Arial 10 plain wordwrap fixed HELP58 SEX FIELD18 string optional absolute 752 971 extent 207 25 0 Field PHONE3 Arial 10 plain wordwrap fixed HELP60 FIELD18 CHECK15 string optional absolute 422 1011 extent 178 25 0 Field WHERE_TAKEN Arial 10 plain wordwrap fixed HELP62 EF18 WHAT_WAS_INJURED_DOING absolute 602 1011 extent 357 25 0 Field WHAT_WAS_INJURED_DOING Arial 10 plain wordwrap fixed HELP63 WHERE_TAKEN FIELD19 0 Field EF18 Arial 9 plain wordwrap fixed CHECK15 WHERE_TAKEN absolute 105 997 extent 315 40 absolute 97 1037 0 Field EF18 Arial 8 plain wordwrap fixed HELP64 WHAT_WAS_INJURED_DOING ESTIMATE_AMOUNT 26 2 absolute 314 1050 extent 106 25 0 Field ESTIMATE_AMOUNT Arial 10 plain wordwrap fixed HELP65 FIELD19 FIELD20 absolute 788 1050 extent 171 25 0 Field WHEN_CAN_PROPERTY_BE_SEEN Arial 10 plain wordwrap fixed HELP67 FIELD20 EF19 absolute 491 1037 0 Field WHEN_CAN_PROPERTY_BE_SEEN Arial 8 plain wordwrap fixed HELP66 ESTIMATE_AMOUNT WHEN_CAN_PROPERTY_BE_SEEN 36 2 absolute 3 1115 extent 567 21 0 Field EF19 Arial 8 plain wordwrap fixed HELP69 WHEN_CAN_PROPERTY_BE_SEEN EF20 absolute 572 1115 extent 214 21 0 Field EF20 Arial 8 plain wordwrap fixed HELP70 EF19 EF21 string optional absolute 788 1115 extent 171 21 0 Field EF21 Arial 8 plain wordwrap fixed HELP71 EF20 EF22 string optional absolute 3 1135 extent 567 21 0 Field EF22 Arial 8 plain wordwrap fixed EF21 EF23 absolute 572 1135 extent 214 21 0 Field EF23 Arial 8 plain wordwrap fixed EF22 EF24 string optional absolute 788 1135 extent 171 21 0 Field EF24 Arial 8 plain wordwrap fixed EF23 REMARKS string optional absolute 63 1157 extent 896 56 0 Field REMARKS wordwrap fixed HELP72 EF24 REPORTED_BY Arial 8 plain absolute 3 1230 extent 177 25 0 Field REPORTED_BY Arial 10 plain wordwrap fixed HELP73 REMARKS REPORTED_TO absolute 182 1230 extent 178 25 0 Field REPORTED_TO Arial 10 plain wordwrap fixed HELP74 REPORTED_BY SIGNATURE_OF_INSURED absolute 362 1230 extent 298 25 0 Field SIGNATURE_OF_INSURED Arial 10 plain wordwrap fixed HELP75 REPORTED_TO SIGNATURE_OF_PRODUCER absolute 662 1230 extent 297 25 0 Field SIGNATURE_OF_PRODUCER Arial 10 plain wordwrap fixed HELP76 SIGNATURE_OF_INSURED next_button absolute 837 34 DATE (MM/DD/YYYY) Helvetica 6 bold absolute 154 34 GENERAL LIABILITY NOTICE OF OCCURRENCE/CLAIM Helvetica 14 bold HELP1 absolute 82 71 PHONE (A/C, No, Ext): -4 Helvetica 6 bold absolute 875 72 extent 72 27 center PREVIOUSLY REPORTED -4 Helvetica 6 bold HELP11 absolute 406 72 NOTICE OF OCCURRENCE -3 Helvetica 6 plain absolute 4 74 AGENCY Helvetica 6 bold absolute 528 74 DATE OF OCCURRENCE AND TIME Helvetica 6 bold HELP9 absolute 764 74 DATE OF CLAIM Helvetica 6 bold absolute 728 78 AM Helvetica 6 plain absolute 406 98 NOTICE OF CLAIM Helvetica 6 plain absolute 728 98 PM Helvetica 6 plain absolute 882 98 YES Helvetica 6 plain absolute 934 98 NO Helvetica 6 plain absolute 388 114 EFFECTIVE DATE Helvetica 6 bold absolute 493 114 EXPIRATION DATE Helvetica 6 bold absolute 683 114 POLICY TYPE Helvetica 6 bold HELP14 absolute 848 114 RETROACTIVE DATE Helvetica 6 bold absolute 634 138 OCCURRENCE Helvetica 6 plain absolute 754 138 CLAIMS MADE Helvetica 6 plain absolute 382 154 COMPANY Helvetica 6 bold absolute 694 154 MISCELLANEOUS INFO (Site & location code) Helvetica 6 bold absolute 490 158 NAIC CODE: Helvetica 6 bold absolute 382 194 POLICY NUMBER Helvetica 6 bold absolute 694 194 REFERENCE NUMBER Helvetica 6 bold absolute 4 198 CODE: Helvetica 6 bold absolute 190 198 SUB CODE: Helvetica 6 bold absolute 4 211 extent 82 27 AGENCY CUSTOMER ID: -4 Helvetica 6 bold absolute 4 236 INSURED Helvetica 8 bold absolute 418 236 CONTACT Helvetica 8 bold absolute 586 239 CONTACT INSURED Helvetica 6 plain absolute 4 255 NAME AND ADDRESS Helvetica 6 bold absolute 418 255 NAME AND ADDRESS Helvetica 6 bold absolute 843 255 WHERE TO CONTACT Helvetica 6 bold absolute 190 259 SOC SEC # OR FEIN: Helvetica 6 bold absolute 847 334 WHEN TO CONTACT Helvetica 6 bold absolute 4 374 RESIDENCE PHONE (A/C, No) Helvetica 6 bold absolute 202 374 BUSINESS PHONE (A/C, No, Ext) Helvetica 6 bold absolute 418 374 RESIDENCE PHONE (A/C, No) Helvetica 6 bold absolute 622 374 BUSINESS PHONE (A/C, No, Ext) Helvetica 6 bold absolute 4 416 OCCURRENCE Helvetica 8 bold absolute 754 434 extent 140 18 AUTHORITY CONTACTED Helvetica 6 bold absolute 4 436 LOCATION OF OCCURRENCE (Include city & state) -3 Helvetica 6 bold absolute 4 481 DESCRIPTION OF OCCURRENCE (Use separate sheet, if necessary) -3 Helvetica 6 bold absolute 4 536 POLICY INFORMATION Helvetica 8 bold HELP34 absolute 4 556 COVERAGE PART OR FORMS (Insert form #s and edition dates) -3 Helvetica 6 bold absolute 7 593 GENERAL AGGREGATE Helvetica 6 bold absolute 145 593 PROD/COMP OP AGG Helvetica 6 bold absolute 290 593 PERS & ADV INJ Helvetica 6 bold absolute 410 593 EACH OCCURRENCE Helvetica 6 bold absolute 558 593 FIRE DAMAGE Helvetica 6 bold absolute 677 593 MEDICAL EXPENSE Helvetica 6 bold absolute 815 593 DEDUCTIBLE Helvetica 6 bold absolute 934 595 PD Helvetica 6 plain absolute 934 614 BI Helvetica 6 plain absolute 4 631 UMBRELLA/ EXCESS -3 Helvetica 6 bold HELP38 absolute 784 631 extent 66 29 PER CLAIM/OCC -4 Helvetica 6 plain absolute 928 631 extent 33 29 SIR/ DED -4 Helvetica 6 plain absolute 94 639 UMBRELLA Helvetica 6 plain absolute 190 639 EXCESS Helvetica 6 plain absolute 244 639 CARRIER: Helvetica 6 bold absolute 484 639 LIMITS: Helvetica 6 bold absolute 640 639 AGGR Helvetica 6 plain absolute 4 656 TYPE OF LIABILITY Helvetica 8 bold HELP42 absolute 613 674 TYPE OF PREMISES Helvetica 6 bold absolute 4 679 PREMISES: INSURED IS Helvetica 6 bold HELP43 absolute 178 679 OWNER Helvetica 6 plain absolute 262 679 TENANT Helvetica 6 plain absolute 346 679 OTHER: Helvetica 6 plain absolute 4 709 OWNER'S NAME & ADDRESS (If not insured) -3 Helvetica 6 bold absolute 613 731 OWNERS PHONE (A/C, No, Ext): -3 Helvetica 6 bold absolute 613 754 TYPE OF PRODUCT Helvetica 6 bold absolute 4 759 PRODUCTS: INSURED IS Helvetica 6 bold HELP47 absolute 178 759 MANUFACTURER Helvetica 6 plain absolute 310 759 VENDOR Helvetica 6 plain absolute 394 759 OTHER: Helvetica 6 plain absolute 4 789 MANUFACTURER'S NAME & ADDRESS (If not insured) -3 Helvetica 6 bold absolute 613 812 MANUFACT PHONE (A/C, No, Ext): -4 Helvetica 6 bold absolute 4 839 WHERE CAN PRODUCT BE SEEN? Helvetica 6 bold absolute 4 857 OTHER LIABILITY IN- CLUDING COMPLETED OPERATIONS (Explain) -3 Helvetica 6 bold absolute 4 896 INJURED/PROPERTY DAMAGED Helvetica 8 bold HELP53 absolute 754 914 PHONE (A/C, No, Ext) Helvetica 6 bold absolute 4 917 NAME & ADDRESS (Injured/Owner) -3 Helvetica 6 bold absolute 4 954 AGE Helvetica 6 bold absolute 52 954 SEX Helvetica 6 bold absolute 88 954 </