ACORD 92 Instructions

ACORD 92 (2/95) - Medical Statement


This form is submitted if the applicant or another driver on the policy has a medical condition/history requiring that further information be provided to the company. Some companies require the form be submitted for all drivers over a certain age. If question #11 on the auto application has been answered "Yes", this form should be completed. The form should be completed and signed by the individual with the medical condition.

IMPORTANT: THIS FORM CANNOT BE USED IN WISCONSIN.

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