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EDI 267 Individual Life, Annuity and Disability Application

Functional Group AD

X12N Insurance Subcommittee

This Draft Standard for Trial Use contains the format and establishes the data contents of the Individual Life, Annuity and Disability Application Transaction Set (267) for use within the context of an Electronic Data Interchange (EDI) environment. The transaction set is used to transmit new business application information among distributors (agents, broker/dealers, etc.), insurance companies and reinsurance companies for the purpose of underwriting an individual life, annuity or disability contract.

Heading

Position
Segment
Name
Max use
  1. To indicate the start of a transaction set and to assign a control number

  2. To indicate the beginning of a transaction set

  3. To specify any or all of a date, a time, or a time period

  4. NM1 Loop Optional
    Repeat >1
    1. To supply the full name of an individual or organizational entity

    2. To specify the location of the named party

    3. To specify the geographic place of the named party

    4. To specify identifying information

    5. To identify a person or office to whom administrative communications should be directed

Detail

Position
Segment
Name
Max use
  1. ACT Loop Mandatory
    Repeat >1
    1. To specify account information

      The ACT loop repeats for each individual application.
    2. To indicate the action to be taken with the information provided or the status of the entity described

    3. To identify a person or office to whom administrative communications should be directed

    4. To specify the currency being used in the transaction set

    5. To specify language, type of usage, and proficiency or fluency

    6. To specify any or all of a date, a time, or a time period

    7. To specify basic item data: item identification, quantity, and price

    8. To specify basic item identification data

    9. To transmit information required to establish payment or remittance activity

    10. To specify a code and the amount or quantity or percentage associated with it

    11. To indicate the total monetary amount

    12. To specify quantity information

    13. To identify and answer yes and no questions, including the date, time, and comments further qualifying the condition

      The YNQ segment is used to report answers to application questions identified in YNQ01.
    14. To specify identifying information

    15. LQ Loop Optional
      Repeat >1
      1. Code to transmit standard industry codes

        The LQ loop is used to report jurisdictional information about the application.
      2. To specify the geographic place of the named party

      3. To specify language, type of usage, and proficiency or fluency

    16. SI Loop Optional
      Repeat >1
      1. To specify service characteristic data

        The SI loop is used to report policy options being exercised.
      2. To indicate the total monetary amount

      3. To specify any or all of a date, a time, or a time period

      4. To specify identifying information

      5. To supply the full name of an individual or organizational entity

      6. To specify the geographic place of the named party

      7. To provide a free-form format that allows the transmission of text information

    17. PID Loop Optional
      Repeat >1
      1. To describe a product or process in coded or free-form format

        The PID loop is used to report coverages at the contract level.
      2. To specify basic item data: item identification, quantity, and price

      3. To indicate the details and status of a product or product activity

      4. To identify and describe underwriting status of submitted applications

      5. To indicate the total monetary amount

      6. To specify a code and the amount or quantity or percentage associated with it

      7. To transmit information required to establish payment or remittance activity

      8. To specify quantity information

      9. To specify any or all of a date, a time, or a time period

      10. To provide a free-form format that allows the transmission of text information

      11. INV Loop Optional
        Repeat >1
        1. To specify type of investment vehicle or account and other basic data about the investment

        2. To specify a code and the amount or quantity or percentage associated with it

        3. To specify any or all of a date, a time, or a time period

        4. To specify quantity information

        5. To specify basic item identification data

        6. To identify rate amounts or percents for a specific cost or other line item

      12. BEN Loop Optional
        Repeat >1
        1. To supply beneficiary, co-participant, and owner information

          The BEN loop is used to report beneficiary information that relates only to the coverage's reported in the PID loop.
        2. To supply the full name of an individual or organizational entity

        3. To specify additional names

        4. To specify the location of the named party

        5. To specify the geographic place of the named party

        6. To specify identifying information

        7. To specify any or all of a date, a time, or a time period

        8. To report information

        9. To specify quantity information

        10. To indicate the total monetary amount

        11. To specify language, type of usage, and proficiency or fluency

        12. To provide a free-form format that allows the transmission of text information

    18. ENT Loop Optional
      Repeat >1
      1. To designate the entities which are parties to a transaction and specify a reference meaningful to those entities

        The ENT loop repeats for each entity associated with the policy.
      2. To define the attributes of a property or an entity

      3. To specify identifying information

      4. To specify basic item identification data

      5. To supply demographic information

      6. To supply additional demographic identification

      7. To provide additional demographic information to the receiving school, institution, or agency to assist in identifying the particular student

      8. To specify language, type of usage, and proficiency or fluency

      9. To identify the explicit relationship between entities, i.e., parent, child, peer

      10. To specify any or all of a date, a time, or a time period

      11. To indicate the total monetary amount

        The AMT segment is used to report financial information for the entity that is not related to a specific product.
      12. To specify a code and the amount or quantity or percentage associated with it

      13. To identify rate amounts or percents for a specific cost or other line item

        The RPA segment is used to allocate commissions that are independent of the product.
      14. To identify and answer yes and no questions, including the date, time, and comments further qualifying the condition

        The YNQ segment reports answers to entity-related questions identified in YNQ01.
      15. To specify quantity information

      16. To provide a free-form format that allows the transmission of text information

      17. NM1 Loop Optional
        Repeat >1
        1. To supply the full name of an individual or organizational entity

          The NM1 loop identifies the entity.
        2. To specify additional names

        3. To specify identifying information

        4. To specify a code and the amount or quantity or percentage associated with it

        5. N3 Loop Optional
          Repeat >1
          1. To specify the location of the named party

          2. To specify the geographic place of the named party

          3. To specify a communication contact number

          4. To specify any or all of a date, a time, or a time period

          5. To specify quantity information

      18. LQ Loop Optional
        Repeat >1
        1. Code to transmit standard industry codes

          The LQ loop reports underwriting requirements.
        2. To indicate the details and status of a product or product activity

        3. To specify any or all of a date, a time, or a time period

        4. To provide a free-form format that allows the transmission of text information

        5. NM1 Loop Optional
          Repeat >1
          1. To supply the full name of an individual or organizational entity

            The NM1 loop identifies information sources for underwriting requirements.
          2. To specify the location of the named party

          3. To specify the geographic place of the named party

          4. To specify identifying information

          5. To specify a communication contact number

          6. To specify language, type of usage, and proficiency or fluency

          7. To specify any or all of a date, a time, or a time period

          8. To provide a free-form format that allows the transmission of text information

      19. BEN Loop Optional
        Repeat >1
        1. To supply beneficiary, co-participant, and owner information

          The BEN loop is used to report beneficiary information that relates only to a specific entity in the ENT loop.
        2. To supply the full name of an individual or organizational entity

        3. To specify additional names

        4. To specify the location of the named party

        5. To specify the geographic place of the named party

        6. To specify identifying information

        7. To specify any or all of a date, a time, or a time period

        8. To report information

        9. To specify quantity information

        10. To indicate the total monetary amount

        11. To specify language, type of usage, and proficiency or fluency

        12. To provide a free-form format that allows the transmission of text information

      20. PID Loop Optional
        Repeat >1
        1. To describe a product or process in coded or free-form format

          The PID loop is used to report on coverages, service features and riders that relate to a specific entity in the ENT loop.
        2. To specify basic item data: item identification, quantity, and price

        3. To indicate the details and status of a product or product activity

        4. To indicate the total monetary amount

        5. To specify quantity information

        6. To specify any or all of a date, a time, or a time period

        7. To identify and answer yes and no questions, including the date, time, and comments further qualifying the condition

        8. To provide a free-form format that allows the transmission of text information

        9. PDL Loop Optional
          Repeat >1
          1. To transmit information required to establish payment or remittance activity

          2. To specify identifying information

        10. INV Loop Optional
          Repeat >1
          1. To specify type of investment vehicle or account and other basic data about the investment

          2. To specify a code and the amount or quantity or percentage associated with it

          3. To specify any or all of a date, a time, or a time period

          4. To identify rate amounts or percents for a specific cost or other line item

        11. BEN Loop Optional
          Repeat >1
          1. To supply beneficiary, co-participant, and owner information

            The BEN loop is used to report beneficiary information that relates only to a coverage, service feature or rider in the PID loop.
          2. To supply the full name of an individual or organizational entity

          3. To specify additional names

          4. To specify the location of the named party

          5. To specify the geographic place of the named party

          6. To specify identifying information

          7. To specify any or all of a date, a time, or a time period

          8. To report information

          9. To specify quantity information

          10. To indicate the total monetary amount

          11. To specify language, type of usage, and proficiency or fluency

          12. To provide a free-form format that allows the transmission of text information

      21. UC Loop Optional
        Repeat >1
        1. To identify the category of underwriting data being transmitted

          The UC loop is used to report additional risk assessment information.
        2. HL Loop Optional
          Repeat >1
          1. To identify dependencies among and the content of hierarchically related groups of data segments

            The HL segment is used to build the varying levels of detail that can be reported in the UC loop for different kinds of risk assessment information.
          2. To report information provider underwriting data in a question and answer format

          3. To identify and answer yes and no questions, including the date, time, and comments further qualifying the condition

            The YNQ segment is used to report answers to risk assessment questions.
          4. To supply the full name of an individual or organizational entity

            The NM1 segment is used to identify parties related to risk assessment information.
          5. To specify the location of the named party

          6. To specify the geographic place of the named party

          7. To specify a communication contact number

          8. To specify any or all of a date, a time, or a time period

          9. To specify quantity information

          10. To provide a free-form format that allows the transmission of text information

          11. To specify a code and the amount or quantity or percentage associated with it

          12. To indicate the total monetary amount

          13. To report information

          14. To provide class of employment information

          15. To describe employment position

          16. To provide employment specifics

          17. To qualify percent amounts and supply percent amounts

          18. To define the source and related information about the income being reported

          19. To specify basic item identification data

          20. To specify identifying information

          21. To report financial information

          22. To specify type of activity information

          23. To report usage of a vehicle

          24. To provide descriptions that identify a specific vehicle

          25. To identify and describe a specific court case

          26. To describe specific administration of justice events and actions

          27. To report use of tobacco, alcohol, drugs or other substances

          28. To report personal health and medical history data

          29. To report information about a person's family health history

          30. To indicate the details and status of a product or product activity

          31. To report military service data

    19. PWK Loop Optional
      Repeat >1
      1. To identify the type or transmission or both of paperwork or supporting information

        The PWK segment is used to report status and disposition of required forms.
      2. To supply the full name of an individual or organizational entity

        The NM1 segment identifies the person completing or signing a form.
      3. To specify the geographic place of the named party

      4. To specify identifying information

      5. To specify any or all of a date, a time, or a time period

      6. To indicate the details and status of a product or product activity

      7. EFI Loop Optional
        Repeat >1
        1. To provide basic information about the electronic format of the interchange data

          The EFI loop is used to transmit images of required forms and signatures.
        2. To transfer binary data in a single data segment and allow identification of the end of the data segment through a count; there is no identification of the internal structure of the binary data in this segment

    20. LX Loop Optional
      Repeat >1
      1. To reference a line number in a transaction set

        The LX loop is used to report payments made with the application or in the future.
      2. PDL Loop Optional
        Repeat >1
        1. To transmit information required to establish payment or remittance activity

        2. To specify identifying information

        3. AMT Loop Optional
          Repeat >1
          1. To indicate the total monetary amount

          2. To identify a party by type of organization, name, and code

            The N1 segment is used to identify payees or payers.
          3. To specify the location of the named party

          4. To specify the geographic place of the named party

          5. To specify basic item identification data

          6. To specify any or all of a date, a time, or a time period

          7. To specify quantity information

          8. To provide a free-form format that allows the transmission of text information

          9. AM1 Loop Optional
            Repeat >1
            1. To specify a code and the amount or quantity or percentage associated with it

              The AM1 loop is used to report tax status of payment subtotals.
            2. INV Loop Optional
              Repeat >1
              1. To specify type of investment vehicle or account and other basic data about the investment

              2. To specify quantity information

              3. To specify any or all of a date, a time, or a time period

              4. To identify rate amounts or percents for a specific cost or other line item

    21. K2 Loop Optional
      Repeat >1
      1. To transmit information in a free-form format for comment or special instruction

      2. To specify any or all of a date, a time, or a time period

      3. To supply the full name of an individual or organizational entity

        The NM1 segment identifies the originator of the administrative message.
  2. To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

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