ACORD 784 Instructions


Section Name Field Name Field and/or Section Description
Use Informal Inquiry Application – Part 2 Medical History Supplement – Medical Condition
Details / Additional Care Providers, ACORD 784, when more space is required to provide
Informal Inquiry Application – Part medical condition details and/or additional care providers.
2 Medical History Supplement –
TITLE Medical Condition Details / IMPORTANT: This form is not filed with any regulator in any jurisdiction. This form
ACORD 784 (2008/01) Additional Care Providers 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) Case ID Insert the identification number that identifies the case in the agency system.
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 Indicate the reason you last saw an additional care provider. Describe the symptoms and
DETAILS (Diagnosis/Symptoms) diagnosis, if known.
MEDICAL CONDITION
DETAILS Tests – Type, Date Results Indicate specific tests and results related to the 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 Indicate any medication or treatment prescribed, including dosage amount, related to
DETAILS Medication / Treatment / Therapy reason last seen.
Additional Information /
MEDICAL CONDITION Complications / Activity
DETAILS Limitations / Recovery Indicate any other information regarding this condition.
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 Indicate the reason you last saw an additional care provider. Describe the symptoms and
DETAILS (Diagnosis/Symptoms) diagnosis, if known.
MEDICAL CONDITION
DETAILS Tests – Type, Date Results Indicate specific tests and results related to the reason last seen.
MEDICAL CONDITION
DETAILS Medical Condition Identifier 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 Indicate any medication or treatment prescribed, including dosage amount, related to
DETAILS Medication / Treatment / Therapy reason last seen.
Additional Information /
MEDICAL CONDITION Complications / Activity
DETAILS Limitations / Recovery Indicate any other information regarding this condition.
ADDITIONAL CARE
PROVIDERS Historical Physician First Name Provide the physician’s first name.
ADDITIONAL CARE
PROVIDERS Physician Last Name Provide the physician’s last name.
ADDITIONAL CARE
PROVIDERS Facility Name Provide the name of thehealth care facility (if applicable)
ADDITIONAL CARE Indicate the telephone number of the personal physician or health care facility. Include
PROVIDERS Phone Number area code and extension (if applicable)
ADDITIONAL CARE Reason Last Seen Indicate the reason you last saw an additional care provider. Describe the symptoms and
PROVIDERS (Diagnosis/Symptoms) diagnosis, if known.
ADDITIONAL CARE
PROVIDERS Tests – Type, Date Results Indicate specific tests and results related to the reason last seen.
ADDITIONAL CARE Indicate the address of thepersonal physician or health care facility. Do not use P.O. Box
PROVIDERS Street Address Line 1 number.
ADDITIONAL CARE
PROVIDERS Line 2 Address – Line 2.
ADDITIONAL CARE PROVIDERS City Indicate the city of the address.
ADDITIONAL CARE PROVIDERS State State of the address.
ADDITIONAL CARE PROVIDERS Zip Zip code, postal code, etc. (country dependent)
ADDITIONAL CARE PROVIDERS Date Last Seen Indicate the date you last saw aprimary care provider.
ADDITIONAL CARE PROVIDERS Medication / Treatment / Therapy Indicate any medication or treatment prescribed, including dosage amount, related to date last seen.
ADDITIONAL CARE PROVIDERS Remarks Use this space for any additional remarks.