Extract all fields and return in json format from the following acord form 130, don't return format name:
 INDIVIDUALS INCLUDED/EXCLUDED
PARTNERS, OFFICERS, RELATIVES TO BE INCLUDED OR EXCLUDED. (Remuneration to be Included must be part of rating Information cestion.)

lerare] AME Bil RELA Ree re | DUTIES CLASS CODE| REMUNERATION
r | Test Excluded Name 4/13/1968 | Excluded from WC 1% | Excluded test duties 02 03

||| Test Included Name 20/12/2963 lmcteaea in we _|2e_| Included test duties f; | ||

PROVIDE INFORMATION FOR THE PAST € YEAR AND USE THE REMARKS SECTION FOR LOS2 DETAILS L | LOGS RUN ATTACHED

CARRIER § POLICY NUMBER scuams AMOUNT PAID RESERVE
co ABC Company
Pos: LOSS HIST POL | 000.00 | 500.00

co ABC Company
rors: PRIOR WORK 1 230.00 | oo

—— = —————

PBR

NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS

GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS, OPERATIONS AND PRODUCTS: MANUFACTURING-RAW MATERIALS, PROCESSES, PROOUCT, EQUIPMENT. CONTRACTOR-TYPE OF WORK,
SUB-CONTRACTS. MERCANTILE-MERCHANDISE, CUSTOMERS, DELIVERIES. SERVICE-TYFE, LOCATION. FARM~ACREAGE, ANIMALS, MACHINERY, SUS-CONTRACTS.

Nature of Business field, test

GENERAL INFORMATION
EXPLAIN ALL "YES" RESPONSES [ves] no] EXPLAIN ALL "YES" RESPONGE® [ves] 10 |
1_ DOES APPLICANT OWN. OPERATE OF LEASE AIRCRAFTIWATERCRAFT? et INONSENERED Lasts years)? NOT APPUCASLE INMO
2 DOIHAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVEID) 1 TH ODED?
- | |. 3. ARE EMPLOYEE HEALTH PLANS PROVIDED? [ [x]

STORING, TREATING, DISCHARGING, APFLYING, DISPOSING, OR T First repeat the request without change, then give your answer.
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