ACORD 764 (2004/03)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 764 (2004/03)
Fair Credit Reporting Act
Disclosure
ACORD 764 is a standard insurance investigative information practices
and consumer report form. This form is signed by the Agent. Not all
features and benefits offered on this application are available with each
carrier's life insurance plans. Be sure to contact the underwriting carrier to
verify the specific benefits available in the plan for which the proposed
insured is applying. Applicant should retain a copy of this form for their
files.
IDENTIFICATION
SECTION
Name and Address of
Insurance Company
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
APPLICANT
First Name
First name of the proposed applicant.
PROPOSED
APPLICANT
Middle Name
Middle name of the proposed applicant.
PROPOSED
APPLICANT
Last Name
Last name of the proposed applicant.
PROPOSED
APPLICANT
Soc. Sec. # or Government
ID #
Social Security Number or Government Identification Number of proposed
applicant.
PROPOSED
APPLICANT
Driver's License #
Indicate the proposed applicant's driver's license number.
PROPOSED
APPLICANT
State
Indicate the state that issued the proposed applicant's driver's license.
PROPOSED
APPLICANT
Proposed Insured's Address
Line 1
Address Type Code - Home. Indicate the legal residence of the proposed
applicant. Do not use P.O. Box number. Check if this address is the
preferred method of mailing.
PROPOSED
APPLICANT
Line 2
Residence address - Line 2.
PROPOSED
APPLICANT
City
Indicate the city of the address.
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 764 (2004/03)
Fair Credit Reporting Act
Disclosure
ACORD 764 is a standard insurance investigative information practices
and consumer report form. This form is signed by the Agent. Not all
features and benefits offered on this application are available with each
carrier's life insurance plans. Be sure to contact the underwriting carrier to
verify the specific benefits available in the plan for which the proposed
insured is applying. Applicant should retain a copy of this form for their
files.
PROPOSED
APPLICANT
State
State of the address.
PROPOSED
APPLICANT
Zip
Zip code, postal code, etc. (country dependent)
PROPOSED
APPLICANT
Date of Birth
Indicate the date of birth of proposed applicant in MM/DD/YYYY format.
Date of birth is required for background investigation purposes only, and
will be used for no other purpose.