%PDF-1.4 %љ 1 0 obj << /Author (ACORD Corporation) /CreationDate (D:20190628170501-04'00') /Creator (Silverlake Software LLC - Forms Dev Environment) /ModDate (D:20240826150614-04'00') /Producer (Silverlake Software LLC - Form Designer - v1.4.19260) /Title (ACORD 0004 2019-09 Acroform) >> endobj 2 0 obj << /AcroForm << /DR << /Font << /F2 3 0 R >> >> /Fields [4 0 R 5 0 R 6 0 R 7 0 R 8 0 R 9 0 R 10 0 R 11 0 R 12 0 R 13 0 R 14 0 R 15 0 R 16 0 R 17 0 R 18 0 R 19 0 R 20 0 R 21 0 R 22 0 R 23 0 R 24 0 R 25 0 R 26 0 R 27 0 R 28 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 34 0 R 35 0 R 36 0 R 37 0 R 38 0 R 39 0 R 40 0 R 41 0 R 42 0 R 43 0 R 44 0 R 45 0 R 46 0 R 47 0 R 48 0 R 49 0 R 50 0 R 51 0 R 52 0 R 53 0 R 54 0 R 55 0 R 56 0 R 57 0 R 58 0 R 59 0 R 60 0 R 61 0 R 62 0 R 63 0 R 64 0 R 65 0 R 66 0 R 67 0 R 68 0 R 69 0 R 70 0 R 71 0 R 72 0 R 73 0 R 74 0 R 75 0 R 76 0 R 77 0 R 78 0 R 79 0 R 80 0 R 81 0 R 82 0 R 83 0 R 84 0 R 85 0 R 86 0 R 87 0 R 88 0 R 89 0 R 90 0 R 91 0 R 92 0 R 93 0 R 94 0 R 95 0 R 96 0 R 97 0 R 98 0 R 99 0 R 100 0 R 101 0 R 102 0 R 103 0 R 104 0 R 105 0 R 106 0 R 107 0 R 108 0 R 109 0 R 110 0 R 111 0 R 112 0 R 113 0 R 114 0 R 115 0 R 116 0 R 117 0 R 118 0 R 119 0 R 120 0 R 121 0 R 122 0 R 123 0 R 124 0 R 125 0 R 126 0 R 127 0 R 128 0 R 129 0 R 130 0 R 131 0 R 132 0 R 133 0 R 134 0 R 135 0 R 136 0 R 137 0 R 138 0 R] >> /Metadata 139 0 R /OpenAction << /JS (function DateV\(event\) { var regEx = /^\\d{1,2}\\/\\d{1,2}\\/\\d{4}$/; if \(event.value!=null && event.value.length>0 && !regEx.test\(event.value\)\) { event.rc = false; app.alert\("The date must be of the format MM/DD/YYYY."\); } };function YesNoK\(event\) { if \(event.change.length>0\) { event.change = event.change.toUpperCase\(\); if \(event.change!="Y" && event.change!="N"\) event.change = ""; } };\nfunction YesNoV\(event\) { if \(event.value!=null\) event.value = event.value.toUpperCase\(\); if \(event.value!="Y" && event.value!="N" && event.value!=""\) event.rc = false; };\n) /S /JavaScript /Type /Action >> /Pages 140 0 R /Type /Catalog >> endobj 3 0 obj << /BaseFont /Arial /Encoding /WinAnsiEncoding /FirstChar 0 /FontDescriptor << /Ascent 905.27 /CapHeight 716.31 /Descent -211.91 /Flags 32 /FontBBox [-45.9 -168.46 1000.0 938.48] /FontName /Arial /ItalicAngle 0.0 /StemV 0.0 /Type /FontDescriptor >> /LastChar 255 /Subtype /Type1 /Type /Font /Widths [0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 277.83 277.83 354.98 556.15 556.15 889.16 666.99 190.92 333.01 333.01 389.16 583.98 277.83 333.01 277.83 277.83 556.15 556.15 556.15 556.15 556.15 556.15 556.15 556.15 556.15 556.15 277.83 277.83 583.98 583.98 583.98 556.15 1015.14 666.99 666.99 722.17 722.17 666.99 610.84 777.83 722.17 277.83 500.0 666.99 556.15 833.01 722.17 777.83 666.99 777.83 722.17 666.99 610.84 722.17 666.99 943.85 666.99 666.99 610.84 277.83 277.83 277.83 469.24 556.15 333.01 556.15 556.15 500.0 556.15 556.15 277.83 556.15 556.15 222.17 222.17 500.0 222.17 833.01 556.15 556.15 556.15 556.15 333.01 500.0 277.83 556.15 500.0 722.17 500.0 500.0 500.0 333.98 259.77 333.98 583.98 0 556.15 0 222.17 556.15 333.01 1000.0 556.15 556.15 333.01 1000.0 666.99 333.01 1000.0 0 610.84 0 0 222.17 222.17 333.01 333.01 350.1 556.15 1000.0 333.01 1000.0 500.0 333.01 943.85 0 500.0 666.99 277.83 333.01 556.15 556.15 556.15 556.15 259.77 556.15 333.01 736.82 370.12 556.15 583.98 333.01 736.82 552.25 399.9 548.83 333.01 333.01 333.01 576.17 537.11 333.01 333.01 333.01 365.23 556.15 833.98 833.98 833.98 610.84 666.99 666.99 666.99 666.99 666.99 666.99 1000.0 722.17 666.99 666.99 666.99 666.99 277.83 277.83 277.83 277.83 722.17 722.17 777.83 777.83 777.83 777.83 777.83 583.98 777.83 722.17 722.17 722.17 722.17 666.99 666.99 610.84 556.15 556.15 556.15 556.15 556.15 556.15 889.16 500.0 556.15 556.15 556.15 556.15 277.83 277.83 277.83 277.83 556.15 556.15 556.15 556.15 556.15 556.15 556.15 548.83 610.84 556.15 556.15 556.15 556.15 500.0 556.15 500.0] >> endobj 4 0 obj << /DV (ACORD 0004 2019-09 Acroform) /F 2 /Ff 1 /FT /Tx /P 141 0 R /Rect [0 1 0 1] /Subtype /Widget /T (Form_EditionIdentifier_A) /TU (The edition identifier of the form including the form number and edition \(the date is typically formatted YYYY/MM\).) /Type /Annot /V (ACORD 0004 2019-09 Acroform) >> endobj 5 0 obj << /AP << /N 142 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 720 241 732] /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 6 0 obj << /AP << /N 143 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 708 241 720] /Subtype /Widget /T (NamedInsured_MailingAddress_LineOne_A) /TU (Enter text: The named insured's mailing address line one. ) /Type /Annot /V (鶹Ƶ) >> endobj 7 0 obj << /AP << /N 144 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 696 241 708] /Subtype /Widget /T (NamedInsured_MailingAddress_LineTwo_A) /TU (Enter text: The named insured's mailing address line two. ) /Type /Annot /V (400 East Main Street - ASB430) >> endobj 8 0 obj << /AP << /N 145 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 684 176 696] /Subtype /Widget /T (NamedInsured_MailingAddress_CityName_A) /TU (Enter text: The named insured's mailing address city name. ) /Type /Annot /V (Frankfort) >> endobj 9 0 obj << /AP << /N 146 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Q 1 /Rect [176 684 194 696] /Subtype /Widget /T (NamedInsured_MailingAddress_StateOrProvinceCode_A) /TU (Enter code: The named insured's mailing address state or province code. ) /Type /Annot /V (KY) >> endobj 10 0 obj << /AP << /N 147 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [194 684 241 696] /Subtype /Widget /T (NamedInsured_MailingAddress_PostalCode_A) /TU (Enter code: The named insured's mailing address postal code. ) /Type /Annot /V (40601) >> endobj 11 0 obj << /AP << /N 148 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 636 90 648] /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 /V (8221) >> endobj 12 0 obj << /AP << /N 149 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [97 636 241 648] /Subtype /Widget /T (NamedInsured_TaxIdentifier_A) /TU (Enter identifier: The tax identifier of the named insured. ) /Type /Annot /V (61-1099712) >> endobj 13 0 obj << /AP << /N 150 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [248 720 464 732] /Subtype /Widget /T (Loss_Insurer_ClaimNumberIdentifier_A) /TU (Enter identifier: The identifier assigned to the claim by the insurer. As used here, the employer should not enter data in this field.) /Type /Annot /V (Liberty Mutual Fire Insurance Co.) >> endobj 14 0 obj << /AP << /N 151 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [472 720 590 732] /Subtype /Widget /T (Loss_ReportPurposeCode_A) /TU (Enter code: The code identifying the purpose of the report. This code is entered by the carrier or the state workers comp board that receives the form. As used here, the employer should not enter data in this field.) /Type /Annot >> endobj 15 0 obj << /AP << /N 152 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [248 696 356 708] /Subtype /Widget /T (Loss_Jurisdiction_JurisdictionCode_A) /TU (Enter code: The state or organization that has final disposition of this claim. The source of this code list is the U.S. Postal service except for injuries/Illness under Federal Jurisdiction which use the Workers' Compensation Insurance Organizations \(WCIO\) Code list. As used here, the employer should not enter data in this field.) /Type /Annot >> endobj 16 0 obj << /AP << /N 153 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [364 696 590 708] /Subtype /Widget /T (Loss_Jurisdiction_ClaimNumberIdentifier_A) /TU (Enter identifier: The identifier assigned to the claim by the jurisdiction. As used here, the employer should not enter data in this field.) /Type /Annot >> endobj 17 0 obj << /AP << /N 154 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [248 672 418 684] /Subtype /Widget /T (Loss_NamedInsured_ClaimNumberIdentifier_A) /TU (Enter identifier: The identifier assigned to the claim by the named insured/employer. ) /Type /Annot >> endobj 18 0 obj << /AP << /N 155 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [425 672 590 684] /Subtype /Widget /T (Loss_OSHACaseNumberIdentifier_A) /TU (Enter identifier: The case number assigned by OSHA \(Occupational Safety and Health Administration\), if applicable. ) /Type /Annot >> endobj 19 0 obj << /AP << /N 156 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [248 648 400 660] /Subtype /Widget /T (Location_PhysicalAddress_LineOne_A) /TU (Enter text: The address line one of the physical location. ) /Type /Annot >> endobj 20 0 obj << /AP << /N 157 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [400 648 464 660] /Subtype /Widget /T (Location_PhysicalAddress_LineTwo_A) /TU (Enter text: The address line two of the physical location. ) /Type /Annot >> endobj 21 0 obj << /AP << /N 158 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [248 636 400 648] /Subtype /Widget /T (Location_PhysicalAddress_CityName_A) /TU (Enter text: The city name of the physical location. ) /Type /Annot >> endobj 22 0 obj << /AP << /N 159 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Q 1 /Rect [400 636 418 648] /Subtype /Widget /T (Location_PhysicalAddress_StateOrProvinceCode_A) /TU (Enter code: The state or province code of the physical location. ) /Type /Annot >> endobj 23 0 obj << /AP << /N 160 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [418 636 464 648] /Subtype /Widget /T (Location_PhysicalAddress_PostalCode_A) /TU (Enter code: The postal code of the physical location. ) /Type /Annot >> endobj 24 0 obj << /AP << /N 161 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [511 660 590 672] /Subtype /Widget /T (Location_ProducerIdentifier_A) /TU (Enter number: The producer assigned number of the location. ) /Type /Annot >> endobj 25 0 obj << /AP << /N 162 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [472 636 590 648] /Subtype /Widget /T (Location_Primary_PhoneNumber_A) /TU (Enter number: The primary phone number of the location. ) /Type /Annot /V (502-229-0920) >> endobj 26 0 obj << /AP << /N 163 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 600 241 612] /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. As used here, this is the licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant.) /Type /Annot /V (Liberty Mutual Insurance Co.) >> endobj 27 0 obj << /AP << /N 164 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 588 241 600] /Subtype /Widget /T (Insurer_MailingAddress_AddressLineOne_A) /TU (Enter text: The first line of the insurer's mailing address. ) /Type /Annot >> endobj 28 0 obj << /AP << /N 165 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 576 241 588] /Subtype /Widget /T (Insurer_MailingAddress_AddressLineTwo_A) /TU (Enter text: The second line of the insurer's mailing address. ) /Type /Annot >> endobj 29 0 obj << /AP << /N 166 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 564 176 576] /Subtype /Widget /T (Insurer_MailingAddress_CityName_A) /TU (Enter text: The city of the insurer's mailing address. ) /Type /Annot >> endobj 30 0 obj << /AP << /N 167 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Q 1 /Rect [176 564 194 576] /Subtype /Widget /T (Insurer_MailingAddress_StateOrProvinceCode_A) /TU (Enter code: The state or province code of the insurer's mailing address. ) /Type /Annot >> endobj 31 0 obj << /AP << /N 168 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [194 564 241 576] /Subtype /Widget /T (Insurer_MailingAddress_PostalCode_A) /TU (Enter code: The postal code of the insurer's mailing address. ) /Type /Annot >> endobj 32 0 obj << /AP << /N 169 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [68 552 241 564] /Subtype /Widget /T (Insurer_Primary_PhoneNumber_A) /TU (Enter number: The primary phone number of the insurer. As used here, the telephone number of the licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant. \(Include area code and extension if applicable\)) /Type /Annot /V (800-362-0000 24 Hrs / 7 Days a Week) >> endobj 33 0 obj << /AA << /V << /JS (DateV\(event\);) /S /JavaScript /Type /Action >> >> /AP << /N 170 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 10 /P 141 0 R /Q 1 /Rect [259 600 324 612] /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. \(MM/DD/YYYY\) ) /Type /Annot /V (07/01/2024) >> endobj 34 0 obj << /AA << /V << /JS (DateV\(event\);) /S /JavaScript /Type /Action >> >> /AP << /N 171 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 10 /P 141 0 R /Q 1 /Rect [259 576 324 588] /Subtype /Widget /T (Policy_ExpirationDate_A) /TU (Enter date: The date on which the terms and conditions of the policy will expire. \(MM/DD/YYYY\) ) /Type /Annot /V (07/01/2025) >> endobj 35 0 obj << /AP << /D << /1 172 0 R /Off 173 0 R >> /N << /1 174 0 R /Off 175 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [245 552 259 564] /Subtype /Widget /T (Policy_SelfInsuredIndicator_A) /TU (Check the box \(if applicable\): Indicates if the insured is self-insured, in whole or in part. ) /Type /Annot >> endobj 36 0 obj << /AP << /N 176 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [342 600 590 612] /Subtype /Widget /T (ClaimAdministrator_FullName_A) /TU (Enter text: The name of the carrier, third party administrator, state fund, or self-insured responsible for administering the claim. ) /Type /Annot /V (KSU WC Claims Contact: Floyd Hockensmith ) >> endobj 37 0 obj << /AP << /N 177 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [342 588 590 600] /Subtype /Widget /T (ClaimAdministrator_MailingAddress_LineOne_A) /TU (Enter text: The first address line of the claim administrator's mailing address. ) /Type /Annot >> endobj 38 0 obj << /AP << /N 178 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [342 576 590 588] /Subtype /Widget /T (ClaimAdministrator_MailingAddress_LineTwo_A) /TU (Enter text: The second address line of the claim administrator's mailing address. ) /Type /Annot >> endobj 39 0 obj << /AP << /N 179 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [342 564 526 576] /Subtype /Widget /T (ClaimAdministrator_MailingAddress_CityName_A) /TU (Enter text: The city of the claim administrator's mailing address. ) /Type /Annot >> endobj 40 0 obj << /AP << /N 180 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Q 1 /Rect [526 564 544 576] /Subtype /Widget /T (ClaimAdministrator_MailingAddress_StateOrProvinceCode_A) /TU (Enter code: The state or province code of the claim administrator's mailing address. ) /Type /Annot >> endobj 41 0 obj << /AP << /N 181 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [544 564 590 576] /Subtype /Widget /T (ClaimAdministrator_MailingAddress_PostalCode_A) /TU (Enter code: The postal code of the claim administrator's mailing address. ) /Type /Annot >> endobj 42 0 obj << /AP << /N 182 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [389 552 590 564] /Subtype /Widget /T (ClaimAdministrator_Primary_PhoneNumber_A) /TU (Enter number: The primary phone number of the claim administrator. ) /Type /Annot /V (502-229-0920) >> endobj 43 0 obj << /AP << /N 183 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 528 137 540] /Subtype /Widget /T (Insurer_TaxIdentifier_A) /TU (Enter identifier: The tax identifier of the insurer. ) /Type /Annot >> endobj 44 0 obj << /AP << /N 184 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [144 528 446 540] /Subtype /Widget /T (Policy_PolicyNumberIdentifier_A) /TU (Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. ) /Type /Annot /V (WC2-Z51-294892-014) >> endobj 45 0 obj << /AP << /N 185 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [454 528 590 540] /Subtype /Widget /T (ClaimAdministrator_TaxIdentifier_A) /TU (Enter identifier: The tax identifier of the claim administrator. ) /Type /Annot /V (N/A) >> endobj 46 0 obj << /AP << /N 186 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [68 516 302 528] /Subtype /Widget /T (Producer_FullName_A) /TU (Enter text: The full name of the producer / agency. ) /Type /Annot /V (AssuredPartners NL, LLC - Louisville, KY) >> endobj 47 0 obj << /AP << /N 187 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [382 516 590 528] /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. As used here, this information can be found on your insurance policy.) /Type /Annot /V (0073 208468) >> endobj 48 0 obj << /AP << /N 188 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 480 144 492] /Subtype /Widget /T (Employee_Surname_A) /TU (Enter text: The employee's last name \(surname\). ) /Type /Annot >> endobj 49 0 obj << /AP << /N 189 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [144 480 227 492] /Subtype /Widget /T (Employee_GivenName_A) /TU (Enter text: The employee's first name \(given name\). ) /Type /Annot >> endobj 50 0 obj << /AP << /N 190 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Q 1 /Rect [227 480 241 492] /Subtype /Widget /T (Employee_OtherGivenNameInitial_A) /TU (Enter text: The employee's middle name or initial \(other given name\). ) /Type /Annot >> endobj 51 0 obj << /AP << /N 191 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 456 241 468] /Subtype /Widget /T (Employee_MailingAddress_LineOne_A) /TU (Enter text: The first address line of the employee's mailing address. ) /Type /Annot >> endobj 52 0 obj << /AP << /N 192 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 444 176 456] /Subtype /Widget /T (Employee_MailingAddress_CityName_A) /TU (Enter text: The city of the employee's mailing address. ) /Type /Annot >> endobj 53 0 obj << /AP << /N 193 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Q 1 /Rect [176 444 194 456] /Subtype /Widget /T (Employee_MailingAddress_StateOrProvinceCode_A) /TU (Enter code: The state or province code of the employee's mailing address. ) /Type /Annot >> endobj 54 0 obj << /AP << /N 194 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [194 444 241 456] /Subtype /Widget /T (Employee_MailingAddress_PostalCode_A) /TU (Enter code: The postal code of the employee's mailing address. ) /Type /Annot >> endobj 55 0 obj << /AP << /N 195 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [79 432 241 444] /Subtype /Widget /T (Employee_EmailAddress_A) /TU (Enter text: The e-mail address for the employee. ) /Type /Annot >> endobj 56 0 obj << /AP << /N 196 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 408 241 420] /Subtype /Widget /T (Employee_Primary_PhoneNumber_A) /TU (Enter number: The primary phone number of the employee. ) /Type /Annot >> endobj 57 0 obj << /AA << /V << /JS (DateV\(event\);) /S /JavaScript /Type /Action >> >> /AP << /N 197 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 10 /P 141 0 R /Q 1 /Rect [248 480 306 492] /Subtype /Widget /T (Employee_BirthDate_A) /TU (Enter date: The employee's birth date. ) /Type /Annot >> endobj 58 0 obj << /AP << /N 198 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [313 480 407 492] /Subtype /Widget /T (Employee_TaxIdentifier_A) /TU (Enter identifier: The tax identifier of the employee. ) /Type /Annot >> endobj 59 0 obj << /AA << /V << /JS (DateV\(event\);) /S /JavaScript /Type /Action >> >> /AP << /N 199 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 10 /P 141 0 R /Q 1 /Rect [414 480 486 492] /Subtype /Widget /T (Employee_HiredDate_A) /TU (Enter date: The hire date of the employee. ) /Type /Annot >> endobj 60 0 obj << /AP << /N 200 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [493 480 590 492] /Subtype /Widget /T (Employee_HiredStateOrProvinceCode_A) /TU (Enter code: The state in which the individual was hired. ) /Type /Annot >> endobj 61 0 obj << /AP << /D << /1 201 0 R /Off 202 0 R >> /N << /1 203 0 R /Off 204 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [245 456 259 468] /Subtype /Widget /T (Employee_Gender_MaleIndicator_A) /TU (Check the box \(if applicable\): Indicates the employee is male. ) /Type /Annot >> endobj 62 0 obj << /AP << /D << /1 205 0 R /Off 206 0 R >> /N << /1 207 0 R /Off 208 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [245 444 259 456] /Subtype /Widget /T (Employee_Gender_FemaleIndicator_A) /TU (Check the box \(if applicable\): Indicates the employee is female. ) /Type /Annot >> endobj 63 0 obj << /AP << /D << /1 209 0 R /Off 210 0 R >> /N << /1 211 0 R /Off 212 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [245 432 259 444] /Subtype /Widget /T (Employee_Gender_UnknownIndicator_A) /TU (Check the box \(if applicable\): Indicates the gender of the employee is unknown. ) /Type /Annot >> endobj 64 0 obj << /AP << /N 213 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [248 408 306 420] /Subtype /Widget /T (Employee_DependentCount_A) /TU (Enter number: The number of dependents of the employee. ) /Type /Annot >> endobj 65 0 obj << /AP << /D << /1 214 0 R /Off 215 0 R >> /N << /1 216 0 R /Off 217 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [310 456 324 468] /Subtype /Widget /T (Employee_MaritalStatus_SingleIndicator_A) /TU (Check the box \(if applicable\): Indicates the employee is single. ) /Type /Annot >> endobj 66 0 obj << /AP << /D << /1 218 0 R /Off 219 0 R >> /N << /1 220 0 R /Off 221 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [310 444 324 456] /Subtype /Widget /T (Employee_MaritalStatus_MarriedIndicator_A) /TU (Check the box \(if applicable\): Indicates the employee is married. ) /Type /Annot >> endobj 67 0 obj << /AP << /D << /1 222 0 R /Off 223 0 R >> /N << /1 224 0 R /Off 225 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [310 432 324 444] /Subtype /Widget /T (Employee_MaritalStatus_SeparatedIndicator_A) /TU (Check the box \(if applicable\): Indicates the employee is separated from their spouse. ) /Type /Annot >> endobj 68 0 obj << /AP << /D << /1 226 0 R /Off 227 0 R >> /N << /1 228 0 R /Off 229 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [310 420 324 432] /Subtype /Widget /T (Employee_MaritalStatus_UnknownIndicator_A) /TU (Check the box \(if applicable\): Indicates the employee's marital status is unknown. ) /Type /Annot >> endobj 69 0 obj << /AP << /N 230 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [414 456 590 468] /Subtype /Widget /T (Employee_Occupation_A) /TU (Enter text: The occupation of the employee. As used here, the occupation of the employee at the time of the accident or exposure.) /Type /Annot >> endobj 70 0 obj << /AP << /N 231 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [414 432 590 444] /Subtype /Widget /T (Employee_EmploymentStatusCode_A) /TU (Enter code: Identifies the employment status of this individual. The valid choices are: Full-Time, Part-Time, Not Employed, Officer, On Strike, Disabled, Retired, Unknown, Apprenticeship Full-Time, Apprenticeship Part-Time, Volunteer, Seasonal and Piece Worker. ) /Type /Annot >> endobj 71 0 obj << /AP << /N 232 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [414 408 590 420] /Subtype /Widget /T (Employee_RatingClassificationCode_A) /TU (Enter code: The rating classification code that the employee's estimated remuneration was assigned to. ) /Type /Annot >> endobj 72 0 obj << /AP << /N 233 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 384 108 396] /Subtype /Widget /T (EmployeePayment_AverageWageAmount_A) /TU (Enter amount: The employee's average wage amount. As used here, the rate at the time of the accident or exposure.) /Type /Annot >> endobj 73 0 obj << /AP << /D << /1 234 0 R /Off 235 0 R >> /N << /1 236 0 R /Off 237 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [137 396 151 408] /Subtype /Widget /T (EmployeePayment_WagePaymentPerDayIndicator_A) /TU (Check the box \(if applicable\): Indicates the average wage amount is paid per day. ) /Type /Annot >> endobj 74 0 obj << /AP << /D << /1 238 0 R /Off 239 0 R >> /N << /1 240 0 R /Off 241 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [137 384 151 396] /Subtype /Widget /T (EmployeePayment_WagePaymentWeeklyIndicator_A) /TU (Check the box \(if applicable\): Indicates the average wage amount is paid per week. ) /Type /Annot >> endobj 75 0 obj << /AP << /D << /1 242 0 R /Off 243 0 R >> /N << /1 244 0 R /Off 245 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [187 396 202 408] /Subtype /Widget /T (EmployeePayment_WagePaymentMonthlyIndicator_A) /TU (Check the box \(if applicable\): Indicates the average wage amount is paid monthly. ) /Type /Annot >> endobj 76 0 obj << /AP << /D << /1 246 0 R /Off 247 0 R >> /N << /1 248 0 R /Off 249 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [187 384 202 396] /Subtype /Widget /T (EmployeePayment_WagePaymentOtherIndicator_A) /TU (Check the box \(if applicable\): Indicates the average wage amount is paid at a frequency other than those listed. ) /Type /Annot >> endobj 77 0 obj << /AP << /N 250 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [230 384 245 396] /Subtype /Widget /T (EmployeePayment_WagePaymentFrequencyCode_A) /TU (Enter code: Indicates the frequency at which the average wage amount is paid. ) /Type /Annot >> endobj 78 0 obj << /AP << /N 251 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [274 384 310 396] /Subtype /Widget /T (EmployeePayment_AverageWeeklyWageAmount_A) /TU (Enter amount: The average weekly wages for the past 52 weeks. ) /Type /Annot >> endobj 79 0 obj << /AP << /N 252 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [313 384 385 396] /Subtype /Widget /T (EmployeeSchedule_DaysPerWeekCount_A) /TU (Enter number: The number of days worked per week. ) /Type /Annot >> endobj 80 0 obj << /AA << /K << /JS (YesNoK\(event\);) /S /JavaScript /Type /Action >> /V << /JS (YesNoV\(event\);) /S /Javascript /Type /Action >> >> /AP << /N 253 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 1 /P 141 0 R /Q 1 /Rect [518 396 533 408] /Subtype /Widget /T (Employee_FullPayDayOfInjuryCode_A) /TU (Enter Y for a Yes response. Input N for No response. Indicates if the injured/ill employee will be paid for the full day of the injury/illness. ) /Type /Annot >> endobj 81 0 obj << /AA << /K << /JS (YesNoK\(event\);) /S /JavaScript /Type /Action >> /V << /JS (YesNoV\(event\);) /S /Javascript /Type /Action >> >> /AP << /N 254 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 1 /P 141 0 R /Q 1 /Rect [518 384 533 396] /Subtype /Widget /T (Employee_SalaryContinuedCode_A) /TU (Enter Y for a Yes response. Input N for No response. Indicates if salary continuance applies. ) /Type /Annot >> endobj 82 0 obj << /AP << /N 255 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 348 76 360] /Subtype /Widget /T (Employee_WorkBeganTime_A) /TU (Enter time: The time of day that work began for the employee on the day of the injury/illness. ) /Type /Annot >> endobj 83 0 obj << /AP << /D << /1 256 0 R /Off 257 0 R >> /N << /1 258 0 R /Off 259 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [79 360 94 372] /Subtype /Widget /T (Employee_WorkBeganTimeAMIndicator_A) /TU (Check the box \(if applicable\): Indicates the employee began work in the morning. ) /Type /Annot >> endobj 84 0 obj << /AP << /D << /1 260 0 R /Off 261 0 R >> /N << /1 262 0 R /Off 263 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [79 348 94 360] /Subtype /Widget /T (Employee_WorkBeganTimePMIndicator_A) /TU (Check the box \(if applicable\): Indicates the employee began work in the afternoon or evening. ) /Type /Annot >> endobj 85 0 obj << /AA << /V << /JS (DateV\(event\);) /S /JavaScript /Type /Action >> >> /AP << /N 264 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 10 /P 141 0 R /Q 1 /Rect [115 348 194 360] /Subtype /Widget /T (Loss_IncidentDate_A) /TU (Enter date: The date that the loss occurred. As used here, the date the claimant actually sustained the injury or exposure \(which is the date that the loss occurred\).) /Type /Annot >> endobj 86 0 obj << /AP << /D << /1 265 0 R /Off 266 0 R >> /N << /1 267 0 R /Off 268 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [198 348 212 360] /Subtype /Widget /T (Loss_IncidentTimeNotDeterminedIndicator_A) /TU (Check the box \(if applicable\): Indicates the incident time could not be determined. ) /Type /Annot >> endobj 87 0 obj << /AP << /N 269 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [259 348 306 360] /Subtype /Widget /T (Loss_IncidentTime_A) /TU (Enter time: The approximate time that the loss occurred. ) /Type /Annot >> endobj 88 0 obj << /AP << /D << /1 270 0 R /Off 271 0 R >> /N << /1 272 0 R /Off 273 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [310 360 324 372] /Subtype /Widget /T (Loss_IncidentTimeAMIndicator_A) /TU (Check the box \(if applicable\): Indicates the loss occurred in the morning. ) /Type /Annot >> endobj 89 0 obj << /AP << /D << /1 274 0 R /Off 275 0 R >> /N << /1 276 0 R /Off 277 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [310 348 324 360] /Subtype /Widget /T (Loss_IncidentTimePMIndicator_A) /TU (Check the box \(if applicable\): Indicates the loss occurred in the afternoon or evening. ) /Type /Annot >> endobj 90 0 obj << /AA << /V << /JS (DateV\(event\);) /S /JavaScript /Type /Action >> >> /AP << /N 278 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 10 /P 141 0 R /Q 1 /Rect [346 348 421 360] /Subtype /Widget /T (ClaimInjuryOrIllness_CurrentLastWorkedDate_A) /TU (Enter date: The date on which the employee last worked. ) /Type /Annot >> endobj 91 0 obj << /AA << /V << /JS (DateV\(event\);) /S /JavaScript /Type /Action >> >> /AP << /N 279 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 10 /P 141 0 R /Q 1 /Rect [428 348 508 360] /Subtype /Widget /T (ClaimInjuryOrIllness_EmployerHadKnowledgeOfInitialDisabilityDate_A) /TU (Enter date: The date the employer was notified or became aware of the employee's work related disability/incapacity. ) /Type /Annot >> endobj 92 0 obj << /AA << /V << /JS (DateV\(event\);) /S /JavaScript /Type /Action >> >> /AP << /N 280 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 10 /P 141 0 R /Q 1 /Rect [515 348 590 360] /Subtype /Widget /T (ClaimInjuryOrIllness_InitialLostTimeDate_A) /TU (Enter date: The first day on which the claimant originally lost time from work due to the occupation injury or disease or as otherwise stated by statute. ) /Type /Annot >> endobj 93 0 obj << /AP << /N 281 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 324 241 336] /Subtype /Widget /T (LossContact_FullName_A) /TU (Enter text: The full name \(First, Middle, Last\) of the individual to be contacted as a\nrepresentative of the insured on all subsequent business relating to this incident. No entry\nis needed if the 'Contact Insured' option is checked. ) /Type /Annot >> endobj 94 0 obj << /AP << /N 282 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [76 312 241 324] /Subtype /Widget /T (LossContact_Primary_PhoneNumber_A) /TU (Enter number: The loss contact's primary telephone number including area code. ) /Type /Annot >> endobj 95 0 obj << /AP << /N 283 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8392704 /FT /Tx /P 141 0 R /Rect [248 312 407 336] /Subtype /Widget /T (ClaimInjuryOrIllness_SpecificInformation_InjuryNatureDescription_A) /TU (Enter text: The description of the nature of the injury or illness being reported. ) /Type /Annot >> endobj 96 0 obj << /AP << /N 284 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8392704 /FT /Tx /P 141 0 R /Rect [414 312 590 336] /Subtype /Widget /T (ClaimInjuryOrIllness_SpecificInformation_BodyPartDescription_A) /TU (Enter text: The description of the part of the body to which the injury occurred. ) /Type /Annot >> endobj 97 0 obj << /AA << /K << /JS (YesNoK\(event\);) /S /JavaScript /Type /Action >> /V << /JS (YesNoV\(event\);) /S /Javascript /Type /Action >> >> /AP << /N 285 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 1 /P 141 0 R /Q 1 /Rect [158 294 173 306] /Subtype /Widget /T (Employee_IncidentOccurredOnPremisesCode_A) /TU (Enter Y for a Yes response. Input N for No response. Indicates if the accident, injury or illness occurred on the employer's premises. ) /Type /Annot >> endobj 98 0 obj << /AP << /N 286 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [248 288 407 300] /Subtype /Widget /T (ClaimInjuryOrIllness_SpecificInformation_InjuryNatureCode_A) /TU (Enter code: The industry code that corresponds to the nature of the injury sustained by the claimant. ) /Type /Annot >> endobj 99 0 obj << /AP << /N 287 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [414 288 590 300] /Subtype /Widget /T (ClaimInjuryOrIllness_SpecificInformation_BodyPartCode_A) /TU (Enter code: The industry code that corresponds to the affected body part. ) /Type /Annot >> endobj 100 0 obj << /AP << /N 288 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8392704 /FT /Tx /P 141 0 R /Rect [22 258 292 270] /Subtype /Widget /T (Loss_WhereOccurredDescription_A) /TU (Enter text: The department or location where accident or illness exposure occurred \(e.g., maintenance department or client's office at 452 Monroe St., Washington, DC 26210\). If the accident or illness exposure did not occur on the employer's premises, enter address or location. Be specific. ) /Type /Annot >> endobj 101 0 obj << /AP << /N 289 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [299 258 590 270] /Subtype /Widget /T (ClaimInjuryOrIllness_EquipmentUsedDescription_A) /TU (Enter text: The description of all equipment, materials, or chemicals employee was using when accident or illness exposure occurred \(e.g., acetylene cutting torch, metal plate\). List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating when the injury or illness occurred. Be specific, for example: decorator's scaffolding, electric sander, paintbrush and paint. Enter "NA" for not applicable if no equipment, materials or chemicals were being used. NOTE: The items listed do not have to be directly involved in the employee's injury or illness. ) /Type /Annot >> endobj 102 0 obj << /AP << /N 290 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8392704 /FT /Tx /P 141 0 R /Rect [22 222 292 234] /Subtype /Widget /T (ClaimInjuryOrIllness_ActivitiesDescription_A) /TU (Enter text: The specific activity the employee was engaged in when the accident or illness exposure occurred, \(e.g., Cutting metal plate for flooring\). Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation for painting. ) /Type /Annot >> endobj 103 0 obj << /AP << /N 291 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8392704 /FT /Tx /P 141 0 R /Rect [299 222 590 234] /Subtype /Widget /T (ClaimInjuryOrIllness_WorkProcessDescription_A) /TU (Enter text: The work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter "NA" for not applicable if employee was not engaged in a work process, e.g., walking along a hallway. ) /Type /Annot >> endobj 104 0 obj << /AP << /N 292 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 186 446 198] /Subtype /Widget /T (ClaimInjuryOrIllness_EventDescription_A) /TU (Enter text: The description of how injury or illness / abnormal health condition occurred. Describe the sequence of events and include any objects or substances that directly injured the employee or made the employee ill, \(e.g., Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against hot metal\). ) /Type /Annot >> endobj 105 0 obj << /AP << /N 293 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [454 186 590 198] /Subtype /Widget /T (ClaimInjuryOrIllness_LossCauseCode_A) /TU (Enter code: The industry code identifying the general cause of loss, occurrence, injury or illness. There are multiple sources for this code list such as the Workers' Compensation Insurance organizations \(WCIO\), Insurance Services Office \(ISO\), Bureau of Labor Statistics. ) /Type /Annot >> endobj 106 0 obj << /AA << /V << /JS (DateV\(event\);) /S /JavaScript /Type /Action >> >> /AP << /N 294 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 10 /P 141 0 R /Q 1 /Rect [22 162 130 174] /Subtype /Widget /T (ClaimInjuryOrIllness_InitialReturnToWorkDate_A) /TU (Enter date: The date the claimant returned to work or is expected to return to work. ) /Type /Annot >> endobj 107 0 obj << /AA << /V << /JS (DateV\(event\);) /S /JavaScript /Type /Action >> >> /AP << /N 295 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 10 /P 141 0 R /Q 1 /Rect [137 162 241 174] /Subtype /Widget /T (Employee_DeathDate_A) /TU (Enter date: The employee's date of death. ) /Type /Annot >> endobj 108 0 obj << /AA << /K << /JS (YesNoK\(event\);) /S /JavaScript /Type /Action >> /V << /JS (YesNoV\(event\);) /S /Javascript /Type /Action >> >> /AP << /N 296 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 1 /P 141 0 R /Q 1 /Rect [468 174 482 186] /Subtype /Widget /T (Employee_SafeguardsProvidedCode_A) /TU (Enter Y for a Yes response. Input N for No response. Indicates the response to the question, "Were safeguards or safety equipment provided?". ) /Type /Annot >> endobj 109 0 obj << /AA << /K << /JS (YesNoK\(event\);) /S /JavaScript /Type /Action >> /V << /JS (YesNoV\(event\);) /S /Javascript /Type /Action >> >> /AP << /N 297 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 1 /P 141 0 R /Q 1 /Rect [468 162 482 174] /Subtype /Widget /T (Employee_SafeguardsUsedCode_A) /TU (Enter Y for a Yes response. Input N for No response. Indicates the response to the question, "Were safeguards or safety equipment provided used?". ) /Type /Annot >> endobj 110 0 obj << /AP << /N 298 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 138 241 150] /Subtype /Widget /T (Physician_FullName_A) /TU (Enter text: The full name of the physician. ) /Type /Annot >> endobj 111 0 obj << /AP << /N 299 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 126 241 138] /Subtype /Widget /T (Physician_MailingAddress_LineOne_A) /TU (Enter text: The physician's first mailing address line. ) /Type /Annot >> endobj 112 0 obj << /AP << /N 300 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 114 241 126] /Subtype /Widget /T (Physician_MailingAddress_LineTwo_A) /TU (Enter text: The physician's second mailing address line. ) /Type /Annot >> endobj 113 0 obj << /AP << /N 301 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [22 102 176 114] /Subtype /Widget /T (Physician_MailingAddress_CityName_A) /TU (Enter text: The physician's mailing address city name. ) /Type /Annot >> endobj 114 0 obj << /AP << /N 302 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Q 1 /Rect [176 102 194 114] /Subtype /Widget /T (Physician_MailingAddress_StateOrProvinceCode_A) /TU (Enter code: The physician's mailing address state or province code. ) /Type /Annot >> endobj 115 0 obj << /AP << /N 303 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [194 102 241 114] /Subtype /Widget /T (Physician_MailingAddress_PostalCode_A) /TU (Enter code: The physician's mailing address postal code. ) /Type /Annot >> endobj 116 0 obj << /AP << /N 304 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [248 138 464 150] /Subtype /Widget /T (Hospital_FullName_A) /TU (Enter text: The name of the hospital. ) /Type /Annot >> endobj 117 0 obj << /AP << /N 305 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [248 126 464 138] /Subtype /Widget /T (Hospital_MailingAddress_LineOne_A) /TU (Enter text: The hospital's mailing address line one. ) /Type /Annot >> endobj 118 0 obj << /AP << /N 306 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [248 114 464 126] /Subtype /Widget /T (Hospital_MailingAddress_LineTwo_A) /TU (Enter text: The hospital's mailing address line two. ) /Type /Annot >> endobj 119 0 obj << /AP << /N 307 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [248 102 400 114] /Subtype /Widget /T (Hospital_MailingAddress_CityName_A) /TU (Enter text: The hospital's mailing address city. ) /Type /Annot >> endobj 120 0 obj << /AP << /N 308 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Q 1 /Rect [400 102 418 114] /Subtype /Widget /T (Hospital_MailingAddress_StateOrProvinceCode_A) /TU (Enter text: The hospital's mailing address state or province code. ) /Type /Annot >> endobj 121 0 obj << /AP << /N 309 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [418 102 464 114] /Subtype /Widget /T (Hospital_MailingAddress_PostalCode_A) /TU (Enter text: The hospital's mailing address line postal code. ) /Type /Annot >> endobj 122 0 obj << /AP << /D << /1 310 0 R /Off 311 0 R >> /N << /1 312 0 R /Off 313 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [468 138 482 150] /Subtype /Widget /T (ClaimInjuryOrIllness_InitialTreatment_NoMedicalTreatmentIndicator_A) /TU (Check the box \(if applicable\): Indicates there was no initial treatment when the claimant was injured. ) /Type /Annot >> endobj 123 0 obj << /AP << /D << /1 314 0 R /Off 315 0 R >> /N << /1 316 0 R /Off 317 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [468 126 482 138] /Subtype /Widget /T (ClaimInjuryOrIllness_InitialTreatment_MinorByEmployerIndicator_A) /TU (Check the box \(if applicable\): Indicates the initial treatment was minor and done by the employer. ) /Type /Annot >> endobj 124 0 obj << /AP << /D << /1 318 0 R /Off 319 0 R >> /N << /1 320 0 R /Off 321 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [468 114 482 126] /Subtype /Widget /T (ClaimInjuryOrIllness_InitialTreatment_MinorByClinicIndicator_A) /TU (Check the box \(if applicable\): Indicates the initial treatment was minor and done by a clinic or hospital. ) /Type /Annot >> endobj 125 0 obj << /AP << /D << /1 322 0 R /Off 323 0 R >> /N << /1 324 0 R /Off 325 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [468 102 482 114] /Subtype /Widget /T (ClaimInjuryOrIllness_InitialTreatment_EmergencyCareIndicator_A) /TU (Check the box \(if applicable\): Indicates emergency care was required when the claimant was injured. ) /Type /Annot >> endobj 126 0 obj << /AP << /D << /1 326 0 R /Off 327 0 R >> /N << /1 328 0 R /Off 329 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [468 90 482 102] /Subtype /Widget /T (ClaimInjuryOrIllness_InitialTreatment_OvernightHospitalizationIndicator_A) /TU (Check the box \(if applicable\): Indicates overnight hospitalization was required when the claimant was injured. ) /Type /Annot >> endobj 127 0 obj << /AP << /D << /1 330 0 R /Off 331 0 R >> /N << /1 332 0 R /Off 333 0 R >> >> /AS /Off /F 4 /Ff 8388608 /FT /Btn /MK << /CA (8) >> /P 141 0 R /Rect [468 78 482 90] /Subtype /Widget /T (ClaimInjuryOrIllness_InitialTreatment_FutureMajorMedicalIndicator_A) /TU (Check the box \(if applicable\): Indicates future major medical/lost time is anticipated for the claimant. ) /Type /Annot >> endobj 128 0 obj << /AP << /N 334 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [72 90 241 102] /Subtype /Widget /T (LossWitness_FullName_A) /TU (Enter text: The name of a person that was a witness to the incident or an uninjured passenger. As used here the person who witnessed how the injury, or illness/abnormal health condition occurred.) /Type /Annot >> endobj 129 0 obj << /AP << /N 335 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [72 78 241 90] /Subtype /Widget /T (LossWitness_PhoneNumber_A) /TU (Enter number: The primary phone number of a person that was a witness to the incident. ) /Type /Annot >> endobj 130 0 obj << /AP << /N 336 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [299 90 468 102] /Subtype /Widget /T (LossWitness_FullName_B) /TU (Enter text: The name of a person that was a witness to the incident or an uninjured passenger. As used here the person who witnessed how the injury, or illness/abnormal health condition occurred.) /Type /Annot >> endobj 131 0 obj << /AP << /N 337 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [299 78 468 90] /Subtype /Widget /T (LossWitness_PhoneNumber_B) /TU (Enter number: The primary phone number of a person that was a witness to the incident. ) /Type /Annot >> endobj 132 0 obj << /AA << /V << /JS (DateV\(event\);) /S /JavaScript /Type /Action >> >> /AP << /N 338 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 10 /P 141 0 R /Q 1 /Rect [22 54 119 66] /Subtype /Widget /T (ClaimInjuryOrIllness_ClaimAdministratorHadKnowledgeOfInjuryDate_A) /TU (Enter date: The date the employer was notified or became aware of the employee's work related disability/incapacity. ) /Type /Annot >> endobj 133 0 obj << /AA << /V << /JS (DateV\(event\);) /S /JavaScript /Type /Action >> >> /AP << /N 339 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /MaxLen 10 /P 141 0 R /Q 1 /Rect [126 54 184 66] /Subtype /Widget /T (Loss_ClaimForm_PreparedDate_A) /TU (Enter date: The date the claim form was completed ) /Type /Annot >> endobj 134 0 obj << /AP << /N 340 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [191 54 324 66] /Subtype /Widget /T (Loss_ClaimForm_PreparerFullName_A) /TU (Enter text: The name of the individual that prepared the claim form. ) /Type /Annot >> endobj 135 0 obj << /AP << /N 341 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [331 54 464 66] /Subtype /Widget /T (Loss_ClaimForm_PreparerTitle_A) /TU (Enter text: The title of the individual that prepared the claim form. ) /Type /Annot >> endobj 136 0 obj << /AP << /N 342 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 141 0 R /Rect [472 54 590 66] /Subtype /Widget /T (Loss_ClaimForm_PreparerPhoneNumber_A) /TU (Enter number: The phone number of the individual that prepared the claim form. ) /Type /Annot >> endobj 137 0 obj << /AP << /N 343 0 R >> /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 344 0 R /Rect [169 48 421 60] /Subtype /Widget /T (Employee_Signature_A) /TU (Sign here: Accommodates the signature of the employee. ) /Type /Annot >> endobj 138 0 obj << /DA (/F2 8 Tf 0 g) /F 4 /Ff 8388608 /FT /Tx /P 345 0 R /Rect [169 48 421 60] /Subtype /Widget /T (Employee_Signature_B) /TU (Sign here: Accommodates the signature of the employee. ) /Type /Annot >> endobj 139 0 obj << /Length 3249 /Subtype /XML /Type /Metadata >> stream ACORD Corporation ACORD 0004 2019-09 Acroform application/pdf 2019-06-28T17:05:01-04:00 Silverlake Software LLC - Forms Dev Environment 2024-08-26T15:06:14-04:00 Silverlake Software LLC - Form Designer - v1.4.19260 uuid:cbb933b3-cf48-403b-9ac3-e7a5a06133ae uuid:e2bfc897-f304-4a90-88b1-3b794ebbeeba endstream endobj 140 0 obj << /Count 5 /Kids [141 0 R 344 0 R 345 0 R 346 0 R 347 0 R] /Type /Pages >> endobj 141 0 obj << /Annots [4 0 R 5 0 R 6 0 R 7 0 R 8 0 R 9 0 R 10 0 R 11 0 R 12 0 R 13 0 R 14 0 R 15 0 R 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