life insurance application and supplement forms - Acord

Commissioner Walter Bell 

Co-Chair, NAIC Interstate Compact 

National Standards Working Group 

Department of Insurance, State of Alabama 

P O Box 303351 

Montgomery, AL 36130-3351 

Commissioner Kevin McCarty 

Co-Chair, NAIC Interstate Compact 

National Standards Working Group 

Department of Financial Services, 

Office of Insurance Regulation 

200 East Gaines Street 

Tallahassee, FL 32399-0300 

August 24, 2005 

Dear Commissioners Bell and McCarty: 

We are writing to you in your roles as Co-Chairs of the NAIC Interstate Compact National Standards Working Group to 

share a document which we believe will be of great assistance to you in your current activities. 

As you may know, ACORD (Association for Cooperative Operations Research and Development) is a global, nonprofit 

insurance association whose mission is to facilitate the development and use of standards for the insurance, reinsurance 

and related financial services industries. For more than three decades, ACORD has served as a forum for insurance 

industry standards development and as such, is affiliated with close to 1,000 insurance and reinsurance companies and 

thousands of agents and brokers, related financial services organizations, software providers, and industry organizations 

worldwide. ACORD also works with other standards bodies to find areas of overlap or gaps to determine the best way to 

combine efforts and develop a unified flow of information. 

The attached document is a working, living document used by ACORD staff and subject to periodic review and update. 

It provides guidelines when ACORD acts as a third party filer submitting life insurance application forms to the states. 

The document also tracks differences in specific states which emanate from practice or statute which must be 

accommodated even in a standardized form. Since your Working Group is about to take on the task of creating a 

"Compact Application," we are pleased to share this information with you during the Speed To Market Summit as we feel 

it may be quite useful. 

ACORD stands ready to be of further assistance in the formation of the Compact. Our experience and expertise in 

creating operational standards within the insurance industry make us uniquely prepared to help with what is, essentially, 

a standards-setting process. As your Working Group’s difficult and important work in developing product standards 

approaches completion, the next steps will be crucial in fulfilling the Compact’s promise of true operational efficiency. 

We would be pleased to participate in any way which furthers the goals of the industry, the regulators, and ultimately, 

insurance consumers themselves. 

Please feel free to contact either of us at any time. 

Sincerely, 

Beth Grossman 

Assistant Vice President, Industry & Government 

Relations ACORD 

bgrossman@acord.org, 845 620 1700, ext. 421 

Ann Henstrand 

Consultant to ACORD, NAIC Matters 

MultiState Associates 

718 832 8455 

cc: Carolyn Johnson Speck, NAIC staff 

Members of the Interstate Compact National Standards 

Working Group 

Members of the Speed to Market Task Force: 

Interested persons

Table of Contents 

LIFE INSURANCE APPLICATION AND SUPPLEMENT FORMS ..........................................................................1 

STATE SPECIFIC FORMS ..............................................................................................................................................2 

FLORIDA ...........................................................................................................................................................................2 

INDIANA ...........................................................................................................................................................................2 

MAINE ..............................................................................................................................................................................2 

MASSACHUSETTS .............................................................................................................................................................2 

MARYLAND ......................................................................................................................................................................3 

MINNESOTA......................................................................................................................................................................4 

MISSOURI .........................................................................................................................................................................4 

NEW JERSEY .....................................................................................................................................................................5 

PENNSYLVANIA ................................................................................................................................................................5 

VERMONT.........................................................................................................................................................................6 

VIRGINIA ..........................................................................................................................................................................6 

WISCONSIN.......................................................................................................................................................................6 

APPENDIX A: ACORD 701..............................................................................................................................................7 

APPENDIX B: ACORD 702............................................................................................................................................13 

APPENDIX C: ACORD 703............................................................................................................................................16 

APPENDIX D: ACORD 754............................................................................................................................................17 

APPENDIX E: ACORD 755............................................................................................................................................20 

APPENDIX F: ACORD 756 ............................................................................................................................................21 

APPENDIX G: ACORD 761............................................................................................................................................22 

APPENDIX H: ACORD 762............................................................................................................................................23 

APPENDIX I: ACORD 763 .............................................................................................................................................24 

APPENDIX J: ACORD 768.............................................................................................................................................25 

New York 

Two Blue Hill Plaza 

3 rd Floor 

Pearl River, NY 10965 

+1 845 620 1700 

+1 845 620 3600 Fax 

www.acord.org 

London 

London Underwriting Centre 

Suite 2/5 

3 Minster Court 

Mincing Lane 

London EC3R 7DD 

+44 (0)20 7617 6400 

+44 (0)20 7617 6401 Fax

Life Insurance Application and Supplement Forms 

Comparison by State 

The following forms are acceptable in all states plus DC, except for: 

• FL, IN, ME, MD, MA, MN, MO, NJ, PA, VT, VA, WI 

• ACORD 701 (2003/09) Life Insurance Application, Part 1 

• ACORD 702 (2004/03) Life Insurance Application, Part 2 Medical History 

• ACORD 703 (2004/03) Medical Examiners Report 

• ACORD 754 (2003/09) Life Insurance Application Supplement, Additional Other Proposed 

Insured 

• ACORD 755 (2003/09) Life Insurance Application Supplement, Additional Owners 

• ACORD 756 (2003/09) Life Insurance Application Supplement, Additional Beneficiaries 

• ACORD 761 (2005/03) Policy Effective Date Supplement, Date of Policy Application* 

• ACORD 762 (2005/03) Policy Effective Date Supplement, Date of Policy Delivery* 

• ACORD 763 (2005/03) Policy Effective Date Supplement, Date Policy Issued* 

• ACORD 768 (2004/03) Life Insurance Application, Part 2 Medical History Supplement 

*KS will not accept a Policy Effective Date Supplement, since KS law states that no 

qualifications are allowed for the start of temporary insurance. 

*NY will approve only one of the three Policy Effective Date Supplements for each 

company. 

Life Insurance Applications and 

Supplement Forms 

[ 1 ]

State Specific Forms 

The following are the state-specific forms, and a description of the differences between the 

state-specific forms and those shown above. 

Florida 

ACORD 702 FL (2004/10), Florida Life 

Insurance Application, Part 2 Medical History. 

1. The form title includes the state name, 

and the edition date is changed to 

2004/10. 

2. The words "disorder or condition" are 

removed from 3. MEDICAL CONDITIONS 

question 52. The item now reads "Any 

other disease not mentioned above." 

3. 4. ADDITIONAL MEDICAL CONDITIONS 

question 67 is replaced with "Within the 

last ten years have you been tested 

positive for exposure to the HIV infection 

or been diagnosed as having ARC or AIDS 

caused by the HIV infection or other 

sickness or condition derived from that 

infection?" 

4. The words "within the last ten years" are 

inserted in 4. ADDITIONAL MEDICAL 

CONDITIONS question 70. 

5. A Florida-specific fraud warning is added 

to the last page. 

ACORD 703 FL (2004/12), Florida Medical 

Examiners Report, and ACORD 768 FL 

(2004/10), Florida Life Insurance Application 

Part 2 Medical History Supplement. 


and the edition dates are changed. 

2. A Florida-specific fraud warning is added 

to the second page. 

Indiana 

ACORD 702 IN (2004/10), Indiana Life 

Insurance Application Part 2, Medical History. 



2004/10. 

2. The words "had any known indication of" 

are deleted from the sentence above the 

questions in 3. MEDICAL CONDITIONS on 

page 1. 

3. The terms AIDS and HIV are defined in 3. 

MEDICAL CONDITIONS question 67 on 

page two. 

4. A fraud warning is added to the last page. 

Maine 

ACORD 701 ME (2003/09), Maine Life 

Insurance Application, Part 1 

1. The form title includes the state name. 

2. The variable information in the DIVIDEND 

OPTIONS and SUPPLEMENTAL 

COVERAGES sections in 3. INSURANCE 

APPLIED FOR on page 1 are removed. 

3. The words "with respect to insurance 

previously applied for" are added to the 

beginning of the first sentence in 10. 

GENERAL INFORMATION question b) 

4. The sentence in 10. GENERAL 

INFORMATION question c) is now followed 

by "if yes, provide details." 

5. The words "if yes, complete appropriate 

supplement" are deleted from 10. 

GENERAL INFORMATION questions 10 g) 

and 10 h). 



[ 2 ]

6. The words "any hazardous activities or 

sports such as" are deleted from 10. 

GENERAL INFORMATION question h), and 

"parachuting, hang gliding and rodeo 

riding" are added. 

7. A caveat is added below 10.GENERAL 

INFORMATION question 10 J) as follows: 

"Answer this question "NO" if you have 

been tested positive for HIV but have not 

developed symptoms of the disease 

AIDS/ARC." 

8. A Maine-specific fraud warning is added to 

the last page. 


Insurance Application, Part 2 Medical History. 



are deleted from the second sentence in 

3. MEDICALCONDITIONS. 

3. 3.MEDICAL CONDITIONS questions 28, 33 

and 52, as well as 4. ADDITIONAL 

MEDICAL INFORMATION questions 55, 61, 

62, 65 and 67, all have the same caveat 

added as is described in item 7 above 

with respect to ACORD 701 ME. 


the last page. 

ACORD 703 ME (2004/03), Maine Medical 

Examiners Report. 



Page 2. 


Insurance Application Supplement, Additional 

Other Proposed Insured. 


2. The same caveat is added to GENERAL 

INFORMATION question 4 j) as is 

described in item 7 above with respect to 

ACORD 701 ME. 


page 3. 


Insurance Application Part 2, Medical History 

Supplement 


2. The same caveat is added to this form as 

is described in item 7 above with respect 

to ACORD 701 ME. 


page 2. 

Massachusetts 

ACORD 701 MA (2004/08), Massachusetts 

Simplified Issue Life Insurance Application, 

Part 1 

1. The form title includes the state name 

and the words "Simplified Issue," and the 

edition date is changed to 2004/08. 


OPTIONS and SUPPLEMENTAL COVERAGE 

sections in 3. INSURANCE APPLIED FOR 

on page 1 are removed. 



beginning of the first sentence in 10 

GENERAL INFORMATION question b). 




5. The words "if "yes" complete appropriate 

supplement" are deleted from 10. 

GENERAL INFORMATION question g) and 

h). 


sports such as" are deleted from 10 




7. A warning is added to 10 GENERAL 

INFORMATION QUESTION i) "Note: a 

"yes" answer to this question could mean 

that coverage could be denied, the 

amount of insurance reduced, or an 

increased premium charged." 



[ 2 ]

8. A statement is added to Section 11 

SIGNATURE "I acknowledge that I have 

received a copy of the Notice of Insurance 

Information Practices." 

9. A Massachusetts-specific fraud warning is 

added to page 6. 


Life Insurance Application, Part 2 Medical 

History 



2004/08. 



3. MEDICALCONDITIONS. 

3. The same statement described in item 8 

for ACORD 701 MA is added to page 3. 




Simplified Issue Life Insurance Application 

Supplement, Additional Other Proposed 

Insured. 

1. The form title and edition date are 

changed, same as ACORD 702 MA. 

2. The same changes are made to the 

GENERAL INFORMATION questions as 

were made to ACORD 701 MA. 



ACORD 755 MA (2004/08), ACORD 756 MA 

(2004/08), ACORD 761 MA (2004/08), 

ACORD 762 MA (2004/08), and ACORD 763 

MA (2004/08) 

1. The form title is changed, same as 

ACORD 701 MA. 


added. 

Maryland 

Every form filed in Maryland is state-specific, 

but only to the extent of the differences 

noted below. 

ACORD 701 MD (2005/06), Maryland Life 



2. The words "NAME OF INSURANCE 

COMPANY MUST BE INSERTED BEFORE 

THIS FORM IS USED" are deleted from 

the COMPANY section at the top of the 

form. 


OPIONS and SUPPLEMENTAL COVERAGES 

sections in 3 INSURANCE APPLIED FOR on 

page 1 are removed. 

4. BIRTH STATE/PROVINCE and BIRTH 

COUNTRY are deleted from 4. PROPOSED 

INSURED on page 1 and from 5. OTHER 

PROPOSED INSURED on page 2. 



first sentence in 10 GENERAL 

INFORMATION question b). 





sports such as "are deleted from 10. 




8. A state-specific fraud warning is added. 

ACORD 754 MD (2005/06), Maryland Life 


Other Proposed Insured. 

The same changes were made to this form as 

are described for ACORD 701 MD above, 

items 1 and 2, and 4 through 7. 

All other application supplements for 

Maryland were changed only to the extent of 

the two differences noted below. 



[ 3 ]

1. The form titles include the state name, 

and the form edition dates are 2004/09. 

2. The words "NAME OF INSURANCE 

COMPANY MUST BE INSERTED BEFORE 

THIS FORM IS USED" is deleted from the 

COMPANY section at the top of each form. 

Minnesota 

ACORD 701 MN (2004/08), Minnesota Life 



and the edition date is 2004/08. 



COVERAGES sections in 3 INSURANCE 








by "if yes provide details." 





riding" are added. Also, the word 

"organized" is inserted in front of "motor 

vehicle". 

6. The word "medically" is inserted in front 

of the words "advised" in two places in 

10. GENERAL INFORMATION question j). 

7. The words "within the past five years" are 

added to the beginning of the sentence in 

10. GENRAL INFORMATION question k). 



Insurance Application, Part 2 Medical History 

1. The form title includes the state’s initials, 


2. The same changes are made to this form 

as are described in items 6 and 7 above 

for ACORD 701 MN. 



Other Proposed Insured 


are described for ACORD 701 MN, items 1 

and 3 through 8. 

In addition to the above changes, ACORD 755 

MN, ACORD 756 MN, ACORD 761 MN, ACORD 

762 MN, and ACORD 763 MN now have the 

state name in the title, and the edition date 

of 2004/08. No other changes were made. 

Missouri 

ACORD 701 MO (2004/08), Missouri Life 




2004/08. 



COVERAGES sections in 3. INSURANCE 


3. Question a) in 10. GENERAL 

INFORMATION is deleted. 
















[ 4 ]

ACORD 754 MO (2004/08), Missouri Life 




are described for ACORD 701 MO above, 

items 1 3 through 7. 


MO, ACORD 756 MO, ACORD 761 MO, ACORD 

762 MO and ACORD 763 MO now have the 

state name in the title, and the edition date 

of 2004/08. No other changes were made. 

New Jersey 

ACORD 701 NJ (2005/02), New Jersey Life 

Insurance Application Part 1 





COVERAGES sections in 3 INSURANCE 


3. Reference to CREDIT CARD in 9 PAYMENT 

PLAN is deleted. 













7. The "standard" fraud warning on the last 

page is replaced by a New Jersey-specific 

fraud warning. 


Insurance Application Part 2, Medical History 



2. The "standard" fraud warning on the last 

page is replaced by a New Jersey-specific 

fraud warning. 





are described above for ACORD 701 NJ, items 

1 and 4 through 7. In addition, an "I agree" 

statement is added to the last page, just 

above the signature line. 


NJ, ACORD 756 NJ, ACORD 761 NJ, ACORD 

762 NJ, ACORD 763 NJ and ACORD 768 NJ 

now have the state name in the title and the 

2005/02 edition date. Also, an "I agree" 

statement identical to the statement added to 

ACORD 754 NJ was added to each of these 

forms, as well as a state-specific fraud 

warning. 

Pennsylvania 

ACORD 701 PA (2004/06), Pennsylvania Life 


1. The state name is added to the title, and 

the edition date is changed to 2004/06. 

2. The same changes are made to this form 

as are described in items 2, 4, 5, and 6 

for ACORD 701 NJ. 

ACORD 754 PA (2004/06), Pennsylvania Life 



The same changes are made to this form as 

are described in items 4 through 6 for ACORD 

701 NJ 

ACORD 755 PA (2004/06), and ACORD 756 

PA (2004/06) 

The state name is included in the title of each 

form, and the edition dates are changed to 

2004/06. 



[ 5 ]

Vermont 

ACORD 702 VT (2004/10), Vermont Life 

Insurance Application, Part 2 Medical History 





3. MEDICAL CONDITIONS. 

3. The words "member of the medical 

profession in" 4. ADDITIONAL MEDICAL 

INFORMATION question 67 are changed 

to "licensed medical physician," and the 

words "or HIV infection" are deleted. . 

ACORD 768 VT (2004/10), Vermont Life 

Insurance Application Part 2 Medical History 

Supplement 

The form title includes the state name, and 

the edition date is 2004/10. 

Virginia 

ACORD701VA(2004/06), 

ACORD754VA(2004/06), 

ACORD755VA(2004/06), 

ACORD756VA(2004/06) 

Wisconsin 

ACORD 702 WI (2004/10), Wisconsin Life 






3.MEDICAL INFORMATION. 

3. The following statement is added to 

question 67 in 4. ADDITIONAL MEDICAL 

INFORMATION: 

"Note: Wisconsin law provides that the 

applicant need not report the results of the 

tests conducted at an anonymous counseling 

and testing site, or home test results." 

ACORD 768 WI (2004/10), Wisconsin Life 


Supplement 

The form title includes the state name, and 

the edition date is 2004/10. 

All four forms were changed as described for 

the same forms in Pennsylvania. 

Please Note: Due to a limitation in the 

number of characters allowable in a form 

number by the Virginia Dept. of Insurance, 

the above form numbers deliberately have no 

spaces. 



[ 6 ]

Appendix A: ACORD 701 



[ 7 ]



[ 8 ]



[ 9 ]



[ 10 ]



[ 11 ]



[ 12 ]

Appendix B: ACORD 702 



[ 13 ]



[ 14 ]



[ 15 ]

Appendix C: ACORD 703 



[ 16 ]

Appendix D: ACORD 754 



[ 17 ]



[ 18 ]



[ 19 ]

Appendix E: ACORD 755 



[ 20 ]

Appendix F: ACORD 756 



[ 21 ]

Appendix G: ACORD 761 



[ 22 ]

Appendix H: ACORD 762 



[ 23 ]

Appendix I: ACORD 763 



[ 24 ]

Appendix J: ACORD 768 



[ 25 ]

life insurance application and supplement forms - Acord

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