Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 751 NC (2006/02)
North Carolina Authorization to
Obtain and Disclose Information
The ACORD North Carolina Authorization to Obtain and Disclose Information form (ACORD 751
NC), is signed by the insured to allow the insurance company to collect and disclose information.
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.
IDENTIFICATION SECTION Company
Name and Address of Insurance
Name of Insurance Company must be inserted before this form is used. Use the actual
name of the company. Do not use group names.
PROPOSED INSURED
First Name
First name of the proposed insured.
PROPOSED INSURED
Middle Name
Middle name of the proposed insured.
PROPOSED INSURED
Last Name
Last name of the proposed insured.
PROPOSED INSURED
Case ID
Insert the identification number that identifies the case in the agency system.
OTHER PROPOSED
INSURED
First Name
First name of the other proposed insured.
OTHER PROPOSED
INSURED
Middle Name
Middle name of the other proposed insured.
OTHER PROPOSED
INSURED
Last Name
Last name of the other proposed insured.
SIGNATURES
Signature of Proposed Insured or
Other Authorized Person
Proposed Insured or Other Authorized Person must sign and date the form.
SIGNATURES
Date
Date the Proposed Insured or Other Authorized Person signed the form.
SIGNATURES
Signature of Other Proposed
Insured
Other Proposed Insured must sign the form (if applicable).
SIGNATURES
Date
Date the Other Proposed Insured signed the form.
SIGNATURES
Signature of Legal Guardian
Legal Guardian must sign the form (if applicable).
SIGNATURES
Date
Date the Legal Guardian signed the form.
751 NC (2006/02)
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