ACORD 655VA Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 655 VA (2009/06) Virginia SmallEmployer GroupHealth InsuranceMedical History Form The title of the form. ACORD 655 VA, Virginia Small Employer Group Health Insurance Medical History Form, may be used by small employers to submit group health insurance applications to insurers in Virginia or to seek rate and coverageinformation from insurers in Virginia. The form should be used by small employers to collect medical history information for a group health insurance application. Use of this form by insurers and small groups is voluntary. This form was developed by the Virginia State Corporation Commission Bureau of Insurance in response to Chapter 546 of Virginia law. The form was released June 9, 2008 in Administrative Letter 2008-08. Contact the Virginia State Corporation Commission – Bureau of Insurance, (804) 371-9074 / (877) 310-6560, for specific questions about the form.