ACORD 782 Instructions


Section Name Field Name Field and/or Section Description
Medical Examiner’s Report, ACORD 782, is designed to be used by the medical examiner to gather medical history at the request of the 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’s life insurance plans. Be sure to contact your agent or the underwriting carrier to verify the specific benefits available in the plan for which the proposed insured is applying.
TITLE ACORD 782 (2008/01) Medical Examiner’s Report 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 broker or agent must be inserted before this form is used.
LAB NAME Lab Name Indicate Laboratory where the testing will be performed, if known.
LAB CODE Lab Code Indicate the unique identifierfor the Laboratory, if known.
SPECIMEN BAR CODE Specimen Bar Code Insert Bar Code label here.
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 Insert the identification number that identifies the case in the agency system.
Legal Residence (No P.O. Box) Indicate the legal residence of the proposed insured. Do not use P.O. Box number.
PROPOSED INSURED (PI) Line 1 Check if this address is the preferred method of mailing.
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) Measured Height (In Shoes) Indicate the height in feet and inches of the proposed insured.
PROPOSED INSURED (PI) Measured Weight (In Clothing) Indicate the weight in pounds of the proposed insured.
For male proposed insureds only, indicate the measurements of the proposed insured’s
PROPOSED INSURED (PI) Measurements (Male Only) chest and waist in inches.
PROPOSED INSURED (PI) Heart Conditions Check all heart conditions that apply.
PROPOSED INSURED (PI) Murmurs If proposed insured has a heart murmur, please provide additional requested information.
PROPOSED INSURED (PI) Blood Pressure Please follow carrier-specific instructions for the number of readings to be taken.
PROPOSED INSURED (PI) Urine Analysis Indicate the albumin and sugar levels in the urine specimen.
PROPOSED INSURED (PI) Pulse Indicate the pulse rate of the proposed insured. There is space provided for three readings.
PROPOSED INSURED (PI) Was the urine sample sent to the lab? Answer the questions “YES” or “NO”.
PROPOSED INSURED (PI) Was an EKG performed? Answer the questions “YES” or “NO”.
PROPOSED INSURED (PI) Was the blood sample sent to the lab? Answer the questions “YES” or “NO”.
PROPOSED INSURED (PI) Was a translator used? Answer the questions “YES” or “NO”.
PROPOSED INSURED (PI) Translator First Name Indicate the first name of the translator.
PROPOSED INSURED (PI) Translator Middle Initial Indicate the middle initial of the translator.
PROPOSED INSURED (PI) Translator Last Name Indicate the last name of the translator.
PROPOSED INSURED (PI) Translator’s Relationship to Proposed Insured Indicate the translator’s relationship to the proposed insured.
PROPOSED INSURED (PI) Language Spoken Indicate the language spoken.
PROPOSED INSURED (PI) Examiner First Name Indicate the first name of the examiner.
PROPOSED INSURED (PI) Examiner Last Name Indicate the last name of the examiner.
PROPOSED INSURED (PI) Date and Time of Examination Indicate the date (mm/dd/yyyy) and time (indicate am or pm) of the examination
PROPOSED INSURED (PI) Location of Exam Indicate the location where the examination was conducted. Space has been provided for “Other”.
PROPOSED INSURED (PI) Paramedical/Examining Company Name Provide the name of the paramedical or examining company.
PROPOSED INSURED (PI) Branch Office Telephone Number Provide the branch office telephone number of the paramedical or examining company.
PROPOSED INSURED (PI) Agent First Name Provide the agent’s first name.
PROPOSED INSURED (PI) Agent Last Name Provide the agent’s last name.
PROPOSED INSURED (PI) General Agent/Managing Agency Name Provide the general agent or managing agency name (if applicable).
PROPOSED INSURED (PI) Branch Office Address Line 1 Provide the branch office address.
PROPOSED INSURED (PI) Line 2 Provide the branch office address.
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) General Agent/Managing Agency Number The identification number of the General Agent/Managing Agency.
SIGNATURE Signature of Examiner Examiner must sign the form.
SIGNATURE Date Date examiner signed the form.