ACORD 752 (2004/01)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 752 (2004/01)
Illustration Certification and
Acknowledgement
ACORD 752 is a standard Illustration Certification and Acknowledgement form. This form
is signed by the insured or applicant and the producer, when a paper illustration is not
produced. It also covers the situation when a computer screen illustration is shown. 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 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
Soc. Sec. # or Government ID #
Social Security Number or Government Identification Number of Proposed Insured.
PROPOSED INSURED
Date of Birth
Indicate the date of birth of proposed insured in MM/DD/YYYY format.
APPLICANT
First Name
First name of the applicant, if other than Proposed Insured.
APPLICANT
Middle Name
Middle name of the applicant, if other than Proposed Insured.
APPLICANT
Last Name
Last name of the applicant, if other than Proposed Insured.
APPLICANT
Case ID
Insert the identification number that identifies the case in the agency system.
APPLICANT
Policy #
Number exactly as it appears on the policy, including prefix and suffix symbols.
PRIMARY PRODUCER
First Name
First name of the primary producer.
PRIMARY PRODUCER
Middle Name
Middle name of the primary producer.
PRIMARY PRODUCER
Last Name
Last name of the primary producer.
PRIMARY PRODUCER
Producer Number
Producer # as assigned by the Insurance Company.
PRIMARY PRODUCER
BGA Name (If Applicable)
The name of the Brokerage General Agency or Brokerage General Agent.
COMPUTER ILLUSTRATION
DATA
Gender
Male, Female or Unisex.
COMPUTER ILLUSTRATION
DATA
Illustrated Age
The person's insurance age as the coverage was issued.
COMPUTER ILLUSTRATION
DATA
Date of Birth
The actual date of birth of the Proposed Insured.
COMPUTER ILLUSTRATION
DATA
Underwriting/ Rate / Risk Class
Underwriting class assumed for the purpose of this illustration. (Both medical and non-
medical risks)
COMPUTER ILLUSTRATION
DATA
Type of Policy
Term, Whole Life, Universal Life, Variable Life
ACORD 752 (2004/01)
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Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 752 (2004/01)
Illustration Certification and
Acknowledgement
ACORD 752 is a standard Illustration Certification and Acknowledgement form. This form
is signed by the insured or applicant and the producer, when a paper illustration is not
produced. It also covers the situation when a computer screen illustration is shown. 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.
COMPUTER ILLUSTRATION
DATA
Product Name
The Insurance Company specific name for the product illustrated.
COMPUTER ILLUSTRATION
DATA
Type of Rider(s)
Additional coverages/benefits as requested, if available, for the product illustrated.
COMPUTER ILLUSTRATION
DATA
Rider Name(s)
The Insurance Company specific name for the rider illustrated.
COMPUTER ILLUSTRATION
DATA
Initial Death Benefit
Initial insurance amount.
COMPUTER ILLUSTRATION
DATA
Premium Amount Illustrated
The dollar amount illustrated.
COMPUTER ILLUSTRATION
DATA
Premium Mode
Mode of premium such as: Annual, Semi Annual, Monthly, Single, Other
COMPUTER ILLUSTRATION
DATA
Number of Policy Years Illustrated
Number of policy years for the product illustrated.
COMPUTER ILLUSTRATION Number of Years Out-of-Pocket
DATA
Premium Illustrated
Number of policy years for the product illustrated.
COMPUTER ILLUSTRATION
DATA
Guaranteed Interest Rate
Guaranteed interest rate for guaranteed period.
COMPUTER ILLUSTRATION
DATA
Dividend Option (If Applicable)
Dividend Type
APPLICANT STATEMENT
Check the appropriate box to indicate
APPLICANT STATEMENT
Signature of Applicant
Applicant must sign the form.
APPLICANT STATEMENT
Date
Date applicant signed the form.
PRODUCER STATEMENT
Check the appropriate box to indicate
ACORD 752 (2004/01)
2 of 3
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 752 (2004/01)
Illustration Certification and
Acknowledgement
ACORD 752 is a standard Illustration Certification and Acknowledgement form. This form
is signed by the insured or applicant and the producer, when a paper illustration is not
produced. It also covers the situation when a computer screen illustration is shown. 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.
PRODUCER STATEMENT
Signature of Producer
Producer must sign the form.
PRODUCER STATEMENT
Date
Date producer signed the form.
ACORD 752 (2004/01)
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