ACORD 765 (2004/01)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 765 (2004/01)
Agent's Report
ACORD 765 is a standard Agents 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
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 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.
PROPOSED INSURED ID #
Soc. Sec. # or Government
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.
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 Agents 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 REPORT
What is the purpose of
insurance ?
Check the appropriate box to indicate the purpose of the insurance. If
Other, specify. Give details including financial information. For amounts
of $500,000 or more, financial statements may be requested.
AGENT'S REPORT
Are you related to the
Proposed Insured(s)?
If Yes, state relationship.
AGENT'S REPORT
How long have you known
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?
AGENT'S REPORT
Have age/amount medical
requirements been ordered?
If Yes, list provider and date of appointment, if known.
AGENT'S REPORT
If the Proposed insured is a
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 Agents 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 REPORT
Does he/she live with his/her
parents?
State the name of the person responsible for the child's support, his or her
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.
AGENT'S REPORT
Does the Proposed Insured
speak english?
If No answer the questions regarding interpretations.
REMARKS
COMMISSION
Name of Licensed Producer
Complete for each licensed agent to receive a commission. Total
commission shares must equal 100%. Each licensed agent will share
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.
COMMISSION
Soc. Sec. # or Government
ID #
Social security number or Government Identification Number of licensed
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 Agents 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.
COMMISSION
General Agent/Managing
Agency Name
The name of the General Agent or Managing General Agency.
COMMISSION
General Agent/Managing
Agency Number
The identification number of the General Agent or Managing General
Agency.
COMMISSION
Agent's Commission Share
%
The percentage of the Commission paid to the Agent for selling the
investment.
COMMISSION
Name of Licensed Producer
Complete for each licensed agent to receive a commission. Total
commission shares must equal 100%. Each licensed agent will share
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.
COMMISSION
Soc. Sec. # or Government
ID #
Social security number or Government Identification Number of licensed
producer.
COMMISSION
Agent Number
The identification number of the Agent.
COMMISSION
Agency Number
The identification number of the Agency.
COMMISSION
General Agent/Managing
Agency Name
The name of the General Agent or Managing General Agency.
COMMISSION
General Agent/Managing
Agency Number
The identification number of the General Agent or Managing General
Agency.
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 765 (2004/01)
Agent's Report
ACORD 765 is a standard Agents 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
Agent's Commission Share
%
The percentage of the Commission paid to the Agent for selling the
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.