ACORD 781 Instructions


Section Name Field Name Field and/or Section Description
Informal Inquiry Application – Part 2 Medical History, ACORD 781, is designed to be used by the medical examiner to gather medical history at the request of a broker or agent, so that an insurance inquiry can be submitted to a carrier. Not all features and benefits offered on this application are available with each carrier’slife insurance plans. Be sure to contact your agent or the underwriting carrier toverify the specific benefits available in the plan for which the proposed insured is applying.
TITLE ACORD 781 (2008/01) Informal InquiryApplication – Part 2 Medical History IMPORTANT: This form is not filed with any regulator in any jurisdiction. This form cannot become part of an insurance policy.
IDENTIFICATION SECTION Name of Requestor Name of agent or broker must be inserted before this form is used.
PROPOSED INSURED (PI) First Name First name of the proposed insured.
PROPOSED INSURED (PI) Middle Name Middle name of the proposed insured.
PROPOSED INSURED (PI) Last Name Last name of the proposed insured.
PROPOSED INSURED (PI) Date of Birth Indicate the date of birth of the proposed insured in MM/DD/YYYY format.
PROPOSED INSURED (PI) Case ID Provide the identification number that identifies the case in the agency system.
Legal Residence (No P.O. Box)
PROPOSED INSURED (PI) Line 1 Indicate the legal residence of the proposed insured. Do not use P.O. Box number.
PROPOSED INSURED (PI) Line 2 Residence address – Line 2.
PROPOSED INSURED (PI) City Indicate the city of the address.
PROPOSED INSURED (PI) State State of the address.
PROPOSED INSURED (PI) Zip Zip code, postal code, etc. (country dependent)
PROPOSED INSURED (PI) SSN # / Gov’t ID Social security number or Government Identification Number of proposed insured.
Indicate whether or not a photo ID of the proposed insured was provided. If “Yes”,
PROPOSED INSURED (PI) Picture ID Verification Yes No indicate the issuing state, the ID type and the expiration date.
PROPOSED INSURED (PI) Drivers Lic State Indicate the state that issued the proposed insured’s driver’s license.
Do you have a physician or a
PRIMARY CARE PROVIDER primary care provider? Check the appropriate box.
PRIMARY CARE PROVIDER Physician First Name Provide the physician’s first name.
PRIMARY CARE PROVIDER Physician Last Name Provide the physician’s last name.
PRIMARY CARE PROVIDER Facility Name Provide the name of the health care facility (if applicable)
Indicate the telephone number of the personal physician or health care facility. Include
PRIMARY CARE PROVIDER Phone Number area code and extension (if applicable)
Reason Last Seen (Diagnosis (Dx) Indicate the reason you last saw a primary care provider. Describe thesymptoms and
PRIMARY CARE PROVIDER /Symptoms) diagnosis, if known.
Indicate specific tests, the date the tests were administered and results related to the
PRIMARY CARE PROVIDER Tests – Type, Date Results reason last seen.
Indicate the address of the personal physician or health care facility. Do not use P.O. Box
PRIMARY CARE PROVIDER Street Address Line 1 number.
PRIMARY CARE PROVIDER Line 2 Address – Line 2.
PRIMARY CARE PROVIDER City Indicate the city of the address.
PRIMARY CARE PROVIDER State State of the address.
PRIMARY CARE PROVIDER Zip Zip code, postal code, etc. (country dependent)
PRIMARY CARE PROVIDER Date Last Seen Indicate the date you last saw a primary care provider.
Medication / Dosage (Rx) / Indicate any medication, including dosage amount, treatment or therapy prescribed,
PRIMARY CARE PROVIDER Treatment (Tx) / Therapy related to reason last seen.
PRIMARY CARE PROVIDER Remarks Use this space for any additional remarks.
Answer YES or NO – Within the past (10) ten years have you been advised of, been treated for, had any known indication of, or been diagnosed by a medical professional with:
MEDICAL CONDITIONS Questions 1 – 52 For any YES answers, please complete MEDICAL CONDITION DETAILS on page 3, Section 6 and/or Supplement if additional space is required
Answer YES or NO – Within the last (5) five years in addition to the information already
ADDITIONAL MEDICAL given, have you had any other: For any YES answers, please complete MEDICAL CONDITION DETAILS on page 3,
INFORMATION Questions 53 – 63 Section 6 and/or Supplement if additional space is required
ADDITIONAL MEDICAL Question 64 – Are you currently
INFORMATION pregnant? Indicate the due date of the pregnancy.
ADDITIONAL MEDICAL INFORMATION Question 65 – Have you been advised to have or do you plan to have hospitalization, surgeries or diagnostic tests that have not yet been completed? Answer YES or NO.
Question 66 – Has there been a weight change of ten (10) pounds or more within the last 12 months?
ADDITIONAL MEDICAL INFORMATION If yes, what was your weight 12 months ago ? Indicate the weight of the proposed insured 12 months ago and the proposed insured’s present weight. Provide the reason for the weight change, if known.
ADDITIONAL MEDICAL
INFORMATION Question 67 – 69 Answer YES or NO.
Question 70 -Other than as
prescribed by a physician, do you or have you ever used marijuana, narcotics,
stimulants, sedatives,
ADDITIONAL MEDICAL INFORMATION hallucinogens, or any prescription drugs? If YES, give name, form, amount, frequency and length of use, and date last used.
ADDITIONAL MEDICAL Indicate the date any form of tobacco or nicotine was last used. Provide any additional
INFORMATION Question 71 requested information.
BIOLOGICAL FAMILY Indicate the gender, age if living or age at death and cause of death for the proposed
CENSUS insured’s parents and siblings (if any).
If any member of the proposed insured’s family has developed heart disease, kidney
BIOLOGICAL FAMILY disease, high blood pressure, diabetes, mental illness/suicide or cancer, indicate the onset
CENSUS age of the disease.
MEDICAL CONDITION
DETAILS Physician First Name Provide the physician’s first name.
MEDICAL CONDITION
DETAILS Physician Last Name Provide the physician’s last name.
MEDICAL CONDITION
DETAILS Last Treated (mm/dd/yyyy) Indicate the date last treated.
MEDICAL CONDITION Reason Last Seen (Diagnosis (Dx) Indicate the reason you last saw a primary care provider. Describe the symptoms and
DETAILS /Symptoms) diagnosis, if known.
MEDICAL CONDITION Indicate specific tests, the date the tests were administered and results related to the
DETAILS Tests – Type, Date Results reason last seen.
MEDICAL CONDITION
DETAILS Medical ConditionIdentifier Specify Item # from Section 3 or 4.
MEDICAL CONDITION
DETAILS Still Under Treatment? Indicate whether or not the proposed insured is still under treatment.
MEDICAL CONDITION
DETAILS Last Episode (mm/yyyy) Indicate the date this condition last occurred.
MEDICAL CONDITION Medication (Rx)/ Treatment (Tx)/ Indicate any medication or treatment prescribed, including dosage amount, related to
DETAILS Therapy reason last seen.
Additional Information /
MEDICAL CONDITION Complications / Activity
DETAILS Limitations / Recovery Indicate any other information regarding this condition.
Proposed Insured must indicate the date and time the application was signed in the
SIGNATURES Signatures presence of a witness. The witness must also sign the application.