| 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. |