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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 92 (2009/10) |
Medical Statement |
The title of the form. The ACORD 92, Medical Statement, 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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IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
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IDENTIFICATION SECTION |
Driver # |
Enter number: The number assigned to the driver by the producer. |
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IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION SECTION |
Agency |
Enter text: The full name of the producer/agency. |
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IDENTIFICATION SECTION |
Policy Number |
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. |
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IDENTIFICATION SECTION |
Effective Date |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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IDENTIFICATION SECTION |
Carrier |
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. |
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IDENTIFICATION SECTION |
NAIC Code |
Enter code: The identification code assigned to the insurer by the NAIC. |
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IDENTIFICATION SECTION |
Named Insured(s) |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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DRIVER INFORMATION |
First Name |
Enter text: The driver's first name (given name). |
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DRIVER INFORMATION |
Middle |
Enter text: The driver's middle name or initial (other given name). |
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DRIVER INFORMATION |
Last Name |
Enter text: The driver's last name (surname). |
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DRIVER INFORMATION |
Date of Birth |
Enter date: The birth date of the driver. |
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DRIVER INFORMATION |
Age |
Enter number: The age of the driver in years. |
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DRIVER INFORMATION |
Sex |
Enter code: The gender of the driver. |
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DRIVER INFORMATION |
Occupation |
Enter text: The occupation of the driver. |
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DRIVER INFORMATION |
Employer's Name and Address |
Enter text: The employer name (business name if self-employed). |
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DRIVER INFORMATION |
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Enter text: The first address line of the employer's physical address. |
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DRIVER INFORMATION |
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Enter text: The second address line of the employer's physical address. |
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DRIVER INFORMATION |
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Enter text: The city of the employer's physical address. |
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DRIVER INFORMATION |
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Enter code: The state code of the employer's physical address. |
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DRIVER INFORMATION |
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Enter code: The postal code of the employer's physical address. |
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DRIVER INFORMATION |
Family Physician's Name and Address |
Enter text: The full name of the physician. |
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DRIVER INFORMATION |
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Enter text: The physician's first mailing address line. |
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DRIVER INFORMATION |
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Enter text: The physician's second mailing address line. |
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DRIVER INFORMATION |
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Enter text: The physician's mailing address city name. |
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DRIVER INFORMATION |
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Enter code: The physician's mailing address state or province code. |
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DRIVER INFORMATION |
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Enter code: The physician's mailing address postal code. |
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DRIVER INFORMATION |
Years Under Physician Care |
Enter number: The number of years under a physician's care. |
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DRIVER INFORMATION |
Date of Last Visit |
Enter date: The date of the last visit to a physician. |
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DRIVER MEDICAL HISTORY |
Have you lost use / sight of either eye? |
Enter Y for a “Yes” response. Input N for “No” response. indicates a response to the question, "Have you lost use/sight of either eye?". |
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DRIVER MEDICAL HISTORY |
Is peripheral (side) vision restricted? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Is the peripheral vision restricted?". |
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DRIVER MEDICAL HISTORY |
Are you color blind? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Are you color blind?". |
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DRIVER MEDICAL HISTORY |
Do you have or have you ever had cataracts? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Do you have or have you ever had cataracts?". |
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DRIVER MEDICAL HISTORY |
Are sight deficiencies corrected by glasses / contacts? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Are sight deficiencies corrected by glasses/contacts?". |
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DRIVER MEDICAL HISTORY |
Date of Last Examination |
Enter date: The date of the last eyesight examination. |
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DRIVER MEDICAL HISTORY |
Are you able to hear normal conversation level? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Are you unable to hear normal conversation level?". |
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DRIVER MEDICAL HISTORY |
Is hearing aid used? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a "Yes" response to the question, "Does the driver use a hearing aid?". |
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DRIVER MEDICAL HISTORY |
Have you ever been treated for heart disease? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a "Yes" response to the question, "Has the driver been treated for heart disease?". |
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DRIVER MEDICAL HISTORY |
Have you ever had a heart attack? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Has the driver had a heart attack?". |
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DRIVER MEDICAL HISTORY |
Do you have a pacemaker? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Does the driver have a pacemaker?". |
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DRIVER MEDICAL HISTORY |
Medication / Dosage used |
Enter text: The description of the heart medication used and its dosage. |
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DRIVER MEDICAL HISTORY |
When was your last treatment or check-up? |
Enter date: The date of the last heart treatment or check up. |
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DRIVER MEDICAL HISTORY |
Have you lost an arm or leg? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Has the driver lost an arm or leg?". |
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DRIVER MEDICAL HISTORY |
Have you lost the use of an arm or leg? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Has the driver lost use of an arm or leg?". |
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DRIVER MEDICAL HISTORY |
Does car have special controls? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Does the car have special controls?". |
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DRIVER MEDICAL HISTORY |
Have you ever been tested for diabetes? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Has the driver been tested for diabetes?" |
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DRIVER MEDICAL HISTORY |
Latest blood sugar test date |
Enter date: The date of the last blood sugar test. |
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DRIVER MEDICAL HISTORY |
Medication / Dosage used |
Enter text: The description of diabetes medication used and its dosage. |
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DRIVER MEDICAL HISTORY |
Method of administration |
Enter text: The method the diabetes medication is administered. |
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DRIVER MEDICAL HISTORY |
Have you ever been treated for epilepsy? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Has the driver been treated for epilepsy?". |
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DRIVER MEDICAL HISTORY |
If yes, kind and date of last seizure |
Enter text: The type of epileptic seizure that has been treated. Include the date of the last seizure. |
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DRIVER MEDICAL HISTORY |
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Enter Date: The date of the last seizure. |
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DRIVER MEDICAL HISTORY |
Medication / Dosage used |
Enter text: The description of the epilepsy medication used and its dosage. |
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DRIVER MEDICAL HISTORY |
Have you ever been treated for high blood pressure? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Has the driver been treated for high blood pressure?". |
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DRIVER MEDICAL HISTORY |
If yes, date of last treatment |
Enter date: The date of the last high blood pressure treatment. |
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DRIVER MEDICAL HISTORY |
Last reading |
Enter text: The last blood pressure reading. |
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DRIVER MEDICAL HISTORY |
Medication / Dosage used |
Enter text: The description of the blood pressure medication and its dosage. |
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DRIVER MEDICAL HISTORY |
Have you ever been treated or received medication for any neurological, mental or emotional problem? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Have you ever been treated or received medication for any neurological, mental or emotional problem?". |
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DRIVER MEDICAL HISTORY |
Have you ever been treated or received medication for any neuromuscular disease (muscular dystrophy, multiple sclerosis, cerebral palsy, etc)? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Have you ever been treated or received medication for any neuromuscular disease (muscular dystrophy, multiple sclerosis, cerebral palsy, etc.)?". |
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DRIVER MEDICAL HISTORY |
Are there any restrictions posted on your drivers license other than glasses? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Are there any restrictions posted on your drivers license other than glasses?". |
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DRIVER MEDICAL HISTORY |
Date of Last Treatment: Convulsions |
Enter date: The date of the last treatment for convulsions. |
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DRIVER MEDICAL HISTORY |
Date of Last Treatment: Fainting Spells |
Enter date: The date of the last treatment for fainting spells. |
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DRIVER MEDICAL HISTORY |
Date of Last Treatment: Loss of Equilibrium |
Enter date: The date of the last treatment for a loss of equilibrium. |
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DRIVER MEDICAL HISTORY |
Date of Last Treatment: Alcohol / Drug Abuse |
Enter date: The date of the last treatment for alcohol or drug abuse. |
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DRIVER MEDICAL HISTORY |
Date of Last Treatment: Mental / Emotional Illness |
Enter date: The date of the last treatment for mental or emotional illness. |
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DRIVER MEDICAL HISTORY |
Date of Last Treatment: Complete Physical Examination |
Enter date: The date of the last complete physical examination. |
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DRIVER MEDICAL HISTORY |
Are you under the care of a physician for any conditions not mentioned above? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a response to the question, "Are you under the care of a physician for any condition not mentioned above?". |
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REMARKS |
Question # |
Enter number: The question number associated with the driver remarks. |
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REMARKS |
Remarks |
Enter text: The remarks associated with a driver. |
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REMARKS |
Question # |
Enter number: The question number associated with the driver remarks. |
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REMARKS |
Remarks |
Enter text: The remarks associated with a driver. |
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REMARKS |
Question # |
Enter number: The question number associated with the driver remarks. |
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REMARKS |
Remarks |
Enter text: The remarks associated with a driver. |
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REMARKS |
Question # |
Enter number: The question number associated with the driver remarks. |
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REMARKS |
Remarks |
Enter text: The remarks associated with a driver. |
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REMARKS |
Question # |
Enter number: The question number associated with the driver remarks. |
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REMARKS |
Remarks |
Enter text: The remarks associated with a driver. |
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REMARKS |
Question # |
Enter number: The question number associated with the driver remarks. |
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REMARKS |
Remarks |
Enter text: The remarks associated with a driver. |
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REMARKS |
Question # |
Enter number: The question number associated with the driver remarks. |
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REMARKS |
Remarks |
Enter text: The remarks associated with a driver. |
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SIGNATURE |
Driver's Signature |
Sign here: Accommodates the signature of the driver. |
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SIGNATURE |
Date |
Enter date: The date the driver signed the form. |
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Edition |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |
