Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 781 (2008/01)
Informal Inquiry Application - Part IMPORTANT: This form is not filed with any regulator in any jurisdiction. This form
2 Medical History
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'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.
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.
PROPOSED INSURED (PI)
Legal Residence (No P.O. Box)
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.
PROPOSED INSURED (PI)
Picture ID Verification Yes No
Indicate whether or not a photo ID of the proposed insured was provided. If Yes,
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.
PRIMARY CARE PROVIDER primary care provider?
Do you have a physician or a
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)
PRIMARY CARE PROVIDER Phone Number
Indicate the telephone number of the personal physician or health care facility. Include
area code and extension (if applicable)
ACORD 781 (2008/01)
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Section Name
Field Name
Field and/or Section Description
PRIMARY CARE PROVIDER /Symptoms)
Reason Last Seen (Diagnosis (Dx)
Indicate the reason you last saw a primary care provider. Describe the symptoms and
diagnosis, if known.
PRIMARY CARE PROVIDER Tests - Type, Date Results
Indicate specific tests, the date the tests were administered and results related to the
reason last seen.
PRIMARY CARE PROVIDER Street Address Line 1
Indicate the address of the personal physician or health care facility. Do not use P.O. Box
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.
PRIMARY CARE PROVIDER Treatment (Tx) / Therapy
Medication / Dosage (Rx) /
Indicate any medication, including dosage amount, treatment or therapy prescribed,
related to reason last seen.
PRIMARY CARE PROVIDER Remarks
Use this space for any additional remarks.
MEDICAL CONDITIONS
Questions 1 - 52
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:
For any YES answers, please complete MEDICAL CONDITION DETAILS on page 3,
Section 6 and/or Supplement if additional space is required
ADDITIONAL MEDICAL
INFORMATION
Questions 53 - 63
Answer YES or NO - Within the last (5) five years in addition to the information already
given, have you had any other:
For any YES answers, please complete MEDICAL CONDITION DETAILS on page 3,
Section 6 and/or Supplement if additional space is required
ADDITIONAL MEDICAL
INFORMATION
Question 64 - Are you currently
pregnant?
Indicate the due date of the pregnancy.
ACORD 781 (2008/01)
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Section Name
Field Name
Field and/or Section Description
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.
ADDITIONAL MEDICAL
INFORMATION
Question 66 - Has there been a
weight change of ten (10) pounds
or more within the last 12 months?
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.
ADDITIONAL MEDICAL
INFORMATION
Question 70 - Other than as
prescribed by a physician, do you
or have you ever used marijuana,
narcotics,
stimulants, sedatives,
hallucinogens, or any prescription
drugs?
If YES, give name, form, amount, frequency and length of use, and date last used.
ADDITIONAL MEDICAL
INFORMATION
Question 71
Indicate the date any form of tobacco or nicotine was last used. Provide any additional
requested information.
BIOLOGICAL FAMILY
CENSUS
Indicate the gender, age if living or age at death and cause of death for the proposed
insured's parents and siblings (if any).
BIOLOGICAL FAMILY
CENSUS
If any member of the proposed insured's family has developed heart disease, kidney
disease, high blood pressure, diabetes, mental illness/suicide or cancer, indicate the onset
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
DETAILS
Reason Last Seen (Diagnosis (Dx)
/Symptoms)
Indicate the reason you last saw a primary care provider. Describe the symptoms and
diagnosis, if known.
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Section Name
Field Name
Field and/or Section Description
MEDICAL CONDITION
DETAILS
Tests - Type, Date Results
Indicate specific tests, the date the tests were administered 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
DETAILS
Medication (Rx)/ Treatment (Tx)/
Therapy
Indicate any medication or treatment prescribed, including dosage amount, related to
reason last seen.
MEDICAL CONDITION
DETAILS
Additional Information /
Complications / Activity
Limitations / Recovery
Indicate any other information regarding this condition.
SIGNATURES
Signatures
Proposed Insured must indicate the date and time the application was signed in the
presence of a witness. The witness must also sign the application.
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