Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 784 (2008/01)
Informal Inquiry Application - Part
2 Medical History Supplement -
Medical Condition Details /
Additional Care Providers
Use Informal Inquiry Application - Part 2 Medical History Supplement - Medical Condition
Details / Additional Care Providers, ACORD 784, when more space is required to provide
medical condition details and/or additional care providers.
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 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
DETAILS
Reason Last Seen
(Diagnosis/Symptoms)
Indicate the reason you last saw an additional care provider. Describe the symptoms and
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
DETAILS
Medication / Treatment / 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.
MEDICAL CONDITION
DETAILS
Physician First Name
Provide the physician's first name.
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Section Name
Field Name
Field and/or Section Description
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/Symptoms)
Indicate the reason you last saw an additional care provider. Describe the symptoms and
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
DETAILS
Medication / Treatment / 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.
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 the health care facility (if applicable)
ADDITIONAL CARE
PROVIDERS
Phone Number
Indicate the telephone number of the personal physician or health care facility. Include
area code and extension (if applicable)
ADDITIONAL CARE
PROVIDERS
Reason Last Seen
(Diagnosis/Symptoms)
Indicate the reason you last saw an additional care provider. Describe the symptoms and
diagnosis, if known.
ADDITIONAL CARE
PROVIDERS
Tests - Type, Date Results
Indicate specific tests and results related to the reason last seen.
ADDITIONAL CARE
PROVIDERS
Street Address Line 1
Indicate the address of the personal physician or health care facility. Do not use P.O. Box
number.
ADDITIONAL CARE
PROVIDERS
Line 2
Address - Line 2.
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Section Name
Field Name
Field and/or Section Description
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 a primary 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.
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