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ACORD Form 765 Agent's Report Instructions
 

 
Section Name Field Name Field and/or Section Description
TITLE ACORD 765 (2004/01) Agent's Report ACORD 765 is a standard Agent’s Report, accepted by multiple carriers. This form is used to answer questions that relate to the Proposed Insured. This form must be completed by the agent/broker who obtained the application on the Proposed Insured and then sent to the new 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.
IDENTIFICATION Name and Address of Name of Insurance Company must be inserted before this form is used.
SECTION Insurance Company 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.
Soc. Sec. # or Government Social Security Number or Government Identification Number of
PROPOSED INSURED ID # Proposed Insured.
PROPOSED INSURED Date of Birth Indicate the date of birth of proposed insured in MM/DD/YYYY format.
AGENT'S REPORT The following questions relate to the proposed insured and are to be answered by the agent or broker of record. This must be completed for all applications. If any question is answered "YES", it must be completed in Remarks.
Section Name Field Name Field and/or Section Description
TITLE ACORD 765 (2004/01) Agent's Report ACORD 765 is a standard Agent’s Report, accepted by multiple carriers. This form is used to answer questions that relate to the Proposed Insured. This form must be completed by the agent/broker who obtained the application on the Proposed Insured and then sent to the new 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.
Check the appropriate box to indicate the purpose of the insurance. If
What is the purpose of "Other", specify. Give details including financial information. For amounts
AGENT'S REPORT insurance ? of $500,000 or more, financial statements may be requested.
Are you related to the
AGENT'S REPORT Proposed Insured(s)? If "Yes", state relationship.
How long have you known
AGENT'S REPORT the Proposed Insured(s)?
AGENT'S REPORT Do you have any information not presented in this application which might in any way affect this risk? If "Yes", explain in Remarks.
AGENT'S REPORT What rate class was quoted?
Have age/amount medical
AGENT'S REPORT requirements been ordered? If "Yes", list provider and date of appointment, if known.
If the Proposed insured is a
AGENT'S REPORT Minor Indicate the amount of insurance in force for each parent or sibling.
Section Name Field Name Field and/or Section Description
TITLE ACORD 765 (2004/01) Agent's Report ACORD 765 is a standard Agent’s Report, accepted by multiple carriers. This form is used to answer questions that relate to the Proposed Insured. This form must be completed by the agent/broker who obtained the application on the Proposed Insured and then sent to the new 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.
State the name of the person responsible for the child's support, his or her
AGENT'S REPORT Does he/she live with his/her parents? relationship to the child and how much insurance is on his or her life. If neither this person or the minor is the owner/applicant, explain in Remarks.
AGENT'S REPORT Were there any Proposed Insured(s) whom you did not see when you took the application? If "Yes", indicate whom.
Does the Proposed Insured
AGENT'S REPORT speak english? If "No" answer the questions regarding interpretations.
REMARKS
Complete for each licensed agent to receive a commission. Total
commission shares must equal 100%. Each licensed agent will share
COMMISSION Name of Licensed Producer equally unless otherwise indicated.
COMMISSION First Name First name of the licensed producer.
COMMISSION Middle Name Middle name of the licensed producer.
COMMISSION Last Name Last name of the licensed producer.
Soc. Sec. # or Government Social security number or Government Identification Number of licensed
COMMISSION ID # producer.
COMMISSION Agent Number The identification number of the Agent.
Section Name Field Name Field and/or Section Description
TITLE ACORD 765 (2004/01) Agent's Report ACORD 765 is a standard Agent’s Report, accepted by multiple carriers. This form is used to answer questions that relate to the Proposed Insured. This form must be completed by the agent/broker who obtained the application on the Proposed Insured and then sent to the new 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.
COMMISSION Agency Number The identification number of the Agency.
General Agent/Managing
COMMISSION Agency Name The name of the General Agent or Managing General Agency.
General Agent/Managing The identification number of the General Agent or Managing General
COMMISSION Agency Number Agency.
Agent's Commission Share The percentage of the Commission paid to the Agent for selling the
COMMISSION % investment.
Complete for each licensed agent to receive a commission. Total
commission shares must equal 100%. Each licensed agent will share
COMMISSION Name of Licensed Producer equally unless otherwise indicated.
COMMISSION First Name First name of the licensed producer.
COMMISSION Middle Name Middle name of the licensed producer.
COMMISSION Last Name Last name of the licensed producer.
Soc. Sec. # or Government Social security number or Government Identification Number of licensed
COMMISSION ID # producer.
COMMISSION Agent Number The identification number of the Agent.
COMMISSION Agency Number The identification number of the Agency.
General Agent/Managing
COMMISSION Agency Name The name of the General Agent or Managing General Agency.
General Agent/Managing The identification number of the General Agent or Managing General
COMMISSION Agency Number Agency.
Section Name Field Name Field and/or Section Description
TITLE ACORD 765 (2004/01) Agent's Report ACORD 765 is a standard Agent’s Report, accepted by multiple carriers. This form is used to answer questions that relate to the Proposed Insured. This form must be completed by the agent/broker who obtained the application on the Proposed Insured and then sent to the new 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.
Agent's Commission Share The percentage of the Commission paid to the Agent for selling the
COMMISSION % investment.
PRODUCER
STATEMENT
PRODUCER
STATEMENT Signature of Producer The producer must sign this form.
PRODUCER
STATEMENT Date of Birth Enter date the form was signed by the producer in MM/DD/YYYY format.
PRODUCER
STATEMENT Signature of Producer The producer must sign this form.
PRODUCER
STATEMENT Date of Birth Enter date the form was signed by the producer in MM/DD/YYYY format.