ACORD 92 (2012/03)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 92 (2012/03)
Medical Statement
ACORD 92, Medical Statement, is submitted if the applicant or
another driver on the policy has a medical condition/history requiring that further
information be provided to the company. Some companies require the form be submitted
for all drivers over a certain age. If the question regarding physical impairment on the
auto application has been answered Yes, this form should be completed. The form
should be completed and signed by the individual with the medical condition.
IMPORTANT: THIS FORM CANNOT BE USED IN MONTANA OR WISCONSIN.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Driver #
Enter number: The number assigned to the driver by the producer.
IDENTIFICATION SECTION Date
Enter date: The date on which the form is completed.
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION SECTION NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Named Insured(s)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
DRIVER INFORMATION
First Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Middle
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Last Name
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Age
Enter number: The age of the driver in years.
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
ACORD 92 (2012/03) rev. 03-30-2012
1 of 4
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Employer's Name and Address
Enter text: The employer name (business name if self-employed).
DRIVER INFORMATION
Enter text: The first address line of the employer's physical address.
DRIVER INFORMATION
Enter text: The second address line of the employer's physical address.
DRIVER INFORMATION
Enter text: The city of the employer's physical address.
DRIVER INFORMATION
Enter code: The state code of the employer's physical address.
DRIVER INFORMATION
Enter code: The postal code of the employer's physical address.
DRIVER INFORMATION
Family Physician's Name and
Address
Enter text: The full name of the physician.
DRIVER INFORMATION
Enter text: The physician's first mailing address line.
DRIVER INFORMATION
Enter text: The physician's second mailing address line.
DRIVER INFORMATION
Enter text: The physician's mailing address city name.
DRIVER INFORMATION
Enter code: The physician's mailing address state or province code.
DRIVER INFORMATION
Enter code: The physician's mailing address postal code.
DRIVER INFORMATION
Years Under Physician Care
Enter number: The number of years under a physician's care.
DRIVER INFORMATION
Date of Last Visit
Enter date: The date of the last visit to a physician.
DRIVER MEDICAL HISTORY Loss of Use / Sight of Either Eye
Enter Y for a Yes response. Input N for No response. Indicates a response to the
condition, Loss of use / sight of either eye?.
DRIVER MEDICAL HISTORY Restricted Peripheral (side) Vision
Enter Y for a Yes response. Input N for No response. Indicates a response to the
condition, Restricted Peripheral (side) Vision?.
DRIVER MEDICAL HISTORY Color Blindness
Enter Y for a Yes response. Input N for No response. Indicates a response to the
condition, Color Blindness.
DRIVER MEDICAL HISTORY Cataracts
Enter Y for a Yes response. Input N for No response. Indicates a response to the
condition, Cataracts.
DRIVER MEDICAL HISTORY Corrective Lenses / Contacts
Enter Y for a Yes response. Input N for No response. Indicates a response to the use
of, Corrective Lenses / Contacts.?.
DRIVER MEDICAL HISTORY Date of Last Eye Examination
Enter date: The date of the last eyesight examination.
DRIVER MEDICAL HISTORY Loss of Hearing
Enter Y for a Yes response. Input N for No response. Indicates a response to the
condition, Loss of Hearing.
DRIVER MEDICAL HISTORY Hearing Aid
Enter Y for a Yes response. Input N for No response. Indicates a response to the use
of, Hearing Aid.
DRIVER MEDICAL HISTORY Heart Disease
Enter Y for a Yes response. Input N for No response. Indicates a response to the
condition, Heart Disease.
DRIVER MEDICAL HISTORY Heart Attack
Enter Y for a Yes response. Input N for No response. Indicates a response to the
condition Heart Attack.
ACORD 92 (2012/03) rev. 03-30-2012
2 of 4
Section Name
Field Name
Field and/or Section Description
DRIVER MEDICAL HISTORY Pacemaker
Enter Y for a Yes response. Input N for No response. Indicates a response to the use
of a, Pacemaker.
DRIVER MEDICAL HISTORY Medication / Dosage Used
Enter text: The description of the heart medication used and its dosage.
DRIVER MEDICAL HISTORY up
Date of Last Treatment or Check-
Enter date: The date of the last heart treatment or check up.
DRIVER MEDICAL HISTORY Loss of Arm or Leg
Enter Y for a Yes response. Input N for No response. Indicates a response to the
condition, Loss of Arm or Leg.
DRIVER MEDICAL HISTORY Loss of Use of an Arm or Leg
Enter Y for a Yes response. Input N for No response. Indicates a response to the
condition, Loss of Use of an Arm or Leg.
DRIVER MEDICAL HISTORY Does Car Have Special Controls?
Enter Y for a Yes response. Input N for No response. Indicates a response to the
question, Does the car have special controls?.
DRIVER MEDICAL HISTORY Diabetes
Enter Y for a Yes response. Input N for No response. Indicates a response to the
condition, Diabetes.
DRIVER MEDICAL HISTORY Latest Blood Sugar Test Date
Enter date: The date of the last blood sugar test.
DRIVER MEDICAL HISTORY Medication / Dosage used
Enter text: The description of diabetes medication used and its dosage.
DRIVER MEDICAL HISTORY Method of Administration
Enter text: The method the diabetes medication is administered.
DRIVER MEDICAL HISTORY Epilepsy
Enter Y for a Yes response. Input N for No response. Indicates a response to the
condition, Epilepsy.
DRIVER MEDICAL HISTORY Kind of Epilepsy
Enter text: The type of epilepsy.
DRIVER MEDICAL HISTORY Date of Last Seizure
Enter Date: The date of the last seizure.
DRIVER MEDICAL HISTORY Medication / Dosage Used
Enter text: The description of the epilepsy medication used and its dosage.
DRIVER MEDICAL HISTORY High Blood Pressure
Enter Y for a Yes response. Input N for No response. Indicates a response to the
condition, High Blood Pressure.
DRIVER MEDICAL HISTORY Date of Last Treatment
Enter date: The date of the last high blood pressure treatment.
DRIVER MEDICAL HISTORY Last Reading
Enter text: The last blood pressure reading.
DRIVER MEDICAL HISTORY Medication / Dosage Used
Enter text: The description of the blood pressure medication and its dosage.
ACORD 92 (2012/03) rev. 03-30-2012
3 of 4
Section Name
Field Name
Field and/or Section Description
DRIVER MEDICAL HISTORY Neurological Impairment
Enter Y for a Yes response. Input N for No response. Indicates a response to the
condition, Neurological Impairment.
DRIVER MEDICAL HISTORY cerebral palsy, etc)
Neuromuscular disease (muscular
dystrophy, multiple sclerosis,
Enter Y for a Yes response. Input N for No response. Indicates a response to the
condition, Neuromuscular disease (muscular dystrophy, multiple sclerosis, cerebral palsy,
etc).
DRIVER MEDICAL HISTORY Than Glasses
Drivers License Restrictions Other
Enter Y for a Yes response. Input N for No response. Indicates a response to the
question, Are there any restrictions posted on your drivers license other than glasses?.
DRIVER MEDICAL HISTORY Convulsions
Date of Last Treatment:
Enter date: Date of Last Treatment: Convulsions
DRIVER MEDICAL HISTORY Spells
Date of Last Treatment: Fainting
Enter date: Date of Last Treatment: Fainting Spells
DRIVER MEDICAL HISTORY Equilibrium
Date of Last Treatment: Loss of
Enter date: Date of Last Treatment: Loss of Equilibrium
DRIVER MEDICAL HISTORY Drug Abuse
Date of Last Treatment: Alcohol /
Enter date: Date of Last Treatment: Alcohol / Drug Abuse
DRIVER MEDICAL HISTORY Emotional Illness
Date of Last Treatment: Mental /
Enter date: The date of the last treatment for mental or emotional illness.
DRIVER MEDICAL HISTORY Examination
Date of Last Complete Physical
Enter date: The date of the last complete physical examination.
DRIVER MEDICAL HISTORY Mentioned Above
Any Existing Condition Not
Enter Y for a Yes response. Input N for No response. Indicates a response to the
question, Any existing condition not mentioned above?.
REMARKS
Remarks
Enter text: The remarks associated with a driver.
SIGNATURE
Driver's Signature
Sign here: Accommodates the signature of the driver.
SIGNATURE
Date
Enter date: The date the driver signed the form.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 92 (2012/03) rev. 03-30-2012
4 of 4