267 Individual Life, Annuity and Disability Application

Functional Group AD

X12N Insurance Subcommittee

This X12 Transaction Set 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
0100
Transaction Set HeaderMandatory
Max 1
To indicate the start of a transaction set and to assign a control number
0200
Beginning SegmentMandatory
Max 1
To indicate the beginning of a transaction set
0300
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
NM1 Loop
Repeat >1
0400
Individual or Organizational NameMandatory
Max 1
To supply the full name of an individual or organizational entity
0500
Party LocationOptional
Max 3
To specify the location of the named party
0600
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
0700
Reference InformationOptional
Max 9
To specify identifying information
0800
Administrative Communications ContactOptional
Max 3
To identify a person or office to whom administrative communications should be directed

Detail

Position
Segment
Name
Max use
N1 Loop
Repeat >1
0010
Party IdentificationMandatory
Max 1
To identify a party by type of organization, name, and code
The N1 loop repeats for each company or intermediate distributor.
0020
Party LocationOptional
Max 3
To specify the location of the named party
0025
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
0030
Extended Reference InformationOptional
Max >1
To transmit identifying information as specified by the Reference Identification Qualifier
0040
Date/Time ReferenceOptional
Max >1
To specify pertinent dates and times
ACT Loop
Repeat >1
0050
Account IdentificationMandatory
Max 1
To specify account information
The ACT loop repeats for each individual application.
0100
Action or Status IndicatorOptional
Max 1
To indicate the action to be taken with the information provided or the status of the entity described
0150
Administrative Communications ContactOptional
Max >1
To identify a person or office to whom administrative communications should be directed
0200
Currency IdentifierOptional
Max 1
To specify the currency being used in the transaction set
0250
Language UseOptional
Max >1
To specify language, type of usage, and proficiency or fluency
0300
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
0350
Basic Baseline Item DataOptional
Max 1
To specify basic item data: item identification, quantity, and price
0400
Item IdentificationOptional
Max >1
To specify basic item identification data
0450
Payment DetailsOptional
Max >1
To transmit information required to establish payment or remittance activity
0500
Informational ValuesOptional
Max >1
To specify a code and the amount or quantity or percentage associated with it
0550
Monetary Amount InformationOptional
Max >1
To indicate the total monetary amount
0575
Quantity InformationOptional
Max >1
To specify quantity information
0600
Yes/No QuestionOptional
Max >1
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.
0650
Reference InformationOptional
Max >1
To specify identifying information
LQ Loop
Repeat >1
0660
Industry Code IdentificationMandatory
Max 1
To identify standard industry codes
The LQ loop is used to report jurisdictional information about the application.
0670
Geographic LocationOptional
Max >1
To specify the geographic place of the named party
0680
Language UseOptional
Max >1
To specify language, type of usage, and proficiency or fluency
SI Loop
Repeat >1
0700
Service Characteristic IdentificationMandatory
Max 1
To specify service characteristic data
The SI loop is used to report policy options being exercised.
0750
Monetary Amount InformationOptional
Max >1
To indicate the total monetary amount
0800
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
0850
Reference InformationOptional
Max >1
To specify identifying information
0900
Individual or Organizational NameOptional
Max 1
To supply the full name of an individual or organizational entity
0950
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
1000
Message TextOptional
Max >1
To provide a free-form format that allows the transmission of text information
PID Loop
Repeat >1
1050
Product/Item DescriptionMandatory
Max 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.
1100
Basic Baseline Item DataOptional
Max 1
To specify basic item data: item identification, quantity, and price
1150
Status of Product or ActivityOptional
Max 1
To indicate the details and status of a product or product activity
1200
Underwriting StatusOptional
Max 1
To identify and describe underwriting status of submitted applications
1250
Monetary Amount InformationOptional
Max >1
To indicate the total monetary amount
1300
Informational ValuesOptional
Max >1
To specify a code and the amount or quantity or percentage associated with it
1350
Payment DetailsOptional
Max >1
To transmit information required to establish payment or remittance activity
1400
Quantity InformationOptional
Max >1
To specify quantity information
1450
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
1500
Message TextOptional
Max >1
To provide a free-form format that allows the transmission of text information
INV Loop
Repeat >1
1550
Investment Vehicle SelectionMandatory
Max 1
To specify type of investment vehicle or account and other basic data about the investment
1600
Informational ValuesOptional
Max >1
To specify a code and the amount or quantity or percentage associated with it
1650
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
1700
Quantity InformationOptional
Max >1
To specify quantity information
1750
Item IdentificationOptional
Max 2
To specify basic item identification data
1800
Rate Amounts or PercentsOptional
Max >1
To identify rate amounts or percents for a specific cost or other line item
BEN Loop
Repeat >1
1850
Beneficiary or Owner InformationMandatory
Max 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.
1900
Individual or Organizational NameOptional
Max 1
To supply the full name of an individual or organizational entity
2000
Party LocationOptional
Max 3
To specify the location of the named party
2050
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
2100
Reference InformationOptional
Max >1
To specify identifying information
2150
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
2250
Quantity InformationOptional
Max >1
To specify quantity information
2270
Monetary Amount InformationOptional
Max >1
To indicate the total monetary amount
2300
Language UseOptional
Max 1
To specify language, type of usage, and proficiency or fluency
2350
Message TextOptional
Max >1
To provide a free-form format that allows the transmission of text information
ENT Loop
Repeat >1
2400
EntityMandatory
Max 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.
2410
Property or Entity IdentificationOptional
Max 2
To define the attributes of a property or an entity
2450
Reference InformationOptional
Max >1
To specify identifying information
2500
Item IdentificationOptional
Max 9
To specify basic item identification data
2550
Demographic InformationOptional
Max 1
To supply demographic information
2600
Additional Demographic InformationOptional
Max 1
To supply additional demographic identification
2620
Additional Individual Demographic InformationOptional
Max 1
To provide additional demographic information to the receiving school, institution, or agency to assist in identifying the particular student
2650
Language UseOptional
Max 1
To specify language, type of usage, and proficiency or fluency
2670
Entity RelationshipOptional
Max 1
To identify the explicit relationship between entities, i.e., parent, child, peer
2700
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
2720
Monetary Amount InformationOptional
Max >1
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.
2750
Informational ValuesOptional
Max >1
To specify a code and the amount or quantity or percentage associated with it
2770
Rate Amounts or PercentsOptional
Max >1
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.
2800
Yes/No QuestionOptional
Max >1
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.
2850
Quantity InformationOptional
Max >1
To specify quantity information
2900
Message TextOptional
Max >1
To provide a free-form format that allows the transmission of text information
NM1 Loop
Repeat >1
2950
Individual or Organizational NameMandatory
Max 1
To supply the full name of an individual or organizational entity
The NM1 loop identifies the entity.
3050
Reference InformationOptional
Max >1
To specify identifying information
3070
Informational ValuesOptional
Max >1
To specify a code and the amount or quantity or percentage associated with it
N3 Loop
Repeat >1
3100
Party LocationMandatory
Max 1
To specify the location of the named party
3150
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
3200
Communication Contact InformationOptional
Max 9
To specify a communication contact number
3250
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
3270
Quantity InformationOptional
Max 1
To specify quantity information
LQ Loop
Repeat >1
3300
Industry Code IdentificationMandatory
Max 1
To identify standard industry codes
The LQ loop reports underwriting requirements.
3350
Status of Product or ActivityOptional
Max 1
To indicate the details and status of a product or product activity
3400
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
3450
Message TextOptional
Max >1
To provide a free-form format that allows the transmission of text information
NM1 Loop
Repeat >1
3500
Individual or Organizational NameMandatory
Max 1
To supply the full name of an individual or organizational entity
The NM1 loop identifies information sources for underwriting requirements.
3550
Party LocationOptional
Max 3
To specify the location of the named party
3600
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
3650
Reference InformationOptional
Max >1
To specify identifying information
3700
Communication Contact InformationOptional
Max 3
To specify a communication contact number
3750
Language UseOptional
Max 1
To specify language, type of usage, and proficiency or fluency
3800
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
3850
Message TextOptional
Max >1
To provide a free-form format that allows the transmission of text information
BEN Loop
Repeat >1
3900
Beneficiary or Owner InformationMandatory
Max 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.
3950
Individual or Organizational NameOptional
Max 1
To supply the full name of an individual or organizational entity
4050
Party LocationOptional
Max 3
To specify the location of the named party
4100
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
4150
Reference InformationOptional
Max >1
To specify identifying information
4200
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
4300
Quantity InformationOptional
Max >1
To specify quantity information
4320
Monetary Amount InformationOptional
Max >1
To indicate the total monetary amount
4350
Language UseOptional
Max 1
To specify language, type of usage, and proficiency or fluency
4400
Message TextOptional
Max >1
To provide a free-form format that allows the transmission of text information
PID Loop
Repeat >1
4450
Product/Item DescriptionMandatory
Max 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.
4500
Basic Baseline Item DataOptional
Max 9
To specify basic item data: item identification, quantity, and price
4550
Status of Product or ActivityOptional
Max 1
To indicate the details and status of a product or product activity
4600
Monetary Amount InformationOptional
Max >1
To indicate the total monetary amount
4650
Quantity InformationOptional
Max >1
To specify quantity information
4700
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
4720
Yes/No QuestionOptional
Max >1
To identify and answer yes and no questions, including the date, time, and comments further qualifying the condition
4750
Message TextOptional
Max >1
To provide a free-form format that allows the transmission of text information
PDL Loop
Repeat >1
4800
Payment DetailsMandatory
Max 1
To transmit information required to establish payment or remittance activity
4850
Reference InformationOptional
Max >1
To specify identifying information
INV Loop
Repeat >1
4900
Investment Vehicle SelectionMandatory
Max 1
To specify type of investment vehicle or account and other basic data about the investment
4950
Informational ValuesOptional
Max >1
To specify a code and the amount or quantity or percentage associated with it
5000
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
5050
Rate Amounts or PercentsOptional
Max >1
To identify rate amounts or percents for a specific cost or other line item
BEN Loop
Repeat >1
5100
Beneficiary or Owner InformationMandatory
Max 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.
5150
Individual or Organizational NameOptional
Max 1
To supply the full name of an individual or organizational entity
5250
Party LocationOptional
Max 3
To specify the location of the named party
5300
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
5350
Reference InformationOptional
Max >1
To specify identifying information
5400
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
5500
Quantity InformationOptional
Max >1
To specify quantity information
5520
Monetary Amount InformationOptional
Max >1
To indicate the total monetary amount
5550
Language UseOptional
Max 1
To specify language, type of usage, and proficiency or fluency
5600
Message TextOptional
Max >1
To provide a free-form format that allows the transmission of text information
UC Loop
Repeat >1
5650
Underwriting CategoryMandatory
Max 1
To identify the category of underwriting data being transmitted
The UC loop is used to report additional risk assessment information.
HL Loop
Repeat >1
5700
Hierarchical LevelMandatory
Max 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.
5750
Underwriting QuestionOptional
Max 1
To report information provider underwriting data in a question and answer format
5800
Yes/No QuestionOptional
Max >1
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.
5850
Individual or Organizational NameOptional
Max 1
To supply the full name of an individual or organizational entity
The NM1 segment is used to identify parties related to risk assessment information.
5900
Party LocationOptional
Max 3
To specify the location of the named party
5950
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
6000
Communication Contact InformationOptional
Max 9
To specify a communication contact number
6050
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
6100
Quantity InformationOptional
Max >1
To specify quantity information
6150
Message TextOptional
Max >1
To provide a free-form format that allows the transmission of text information
6200
Informational ValuesOptional
Max >1
To specify a code and the amount or quantity or percentage associated with it
6250
Monetary Amount InformationOptional
Max >1
To indicate the total monetary amount
6350
Employment ClassOptional
Max 1
To provide class of employment information
6400
Employment PositionOptional
Max 1
To describe employment position
6450
EmployerOptional
Max 1
To provide employment specifics
6500
Percent AmountsOptional
Max >1
To qualify percent amounts and supply percent amounts
6550
Source of IncomeOptional
Max >1
To define the source and related information about the income being reported
6600
Item IdentificationOptional
Max 2
To specify basic item identification data
6650
Reference InformationOptional
Max >1
To specify identifying information
6700
Asset LiabilityOptional
Max >1
To report financial information
6750
Type of ActivityOptional
Max >1
To specify type of activity information
6850
Vehicle InformationOptional
Max >1
To provide descriptions that identify a specific vehicle
6900
Case DescriptionOptional
Max >1
To identify and describe a specific court case
6950
Administration of Justice Event DescriptionOptional
Max >1
To describe specific administration of justice events and actions
7000
Substance UseOptional
Max >1
To report use of tobacco, alcohol, drugs or other substances
7050
Underwriting ConsiderationsOptional
Max >1
To report personal health and medical history data
7100
Family HistoryOptional
Max >1
To report information about a person's family health history
7150
Status of Product or ActivityOptional
Max 1
To indicate the details and status of a product or product activity
PWK Loop
Repeat >1
7250
PaperworkMandatory
Max 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.
7300
Individual or Organizational NameOptional
Max 1
To supply the full name of an individual or organizational entity
The NM1 segment identifies the person completing or signing a form.
7350
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
7400
Reference InformationOptional
Max >1
To specify identifying information
7450
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
7500
Status of Product or ActivityOptional
Max 1
To indicate the details and status of a product or product activity
EFI Loop
Repeat >1
7550
Electronic Format IdentificationMandatory
Max 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.
7600
Binary Data SegmentMandatory
Max 1
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
LX Loop
Repeat >1
7650
Transaction Set Line NumberMandatory
Max 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.
PDL Loop
Repeat >1
7700
Payment DetailsMandatory
Max 1
To transmit information required to establish payment or remittance activity
7750
Reference InformationOptional
Max >1
To specify identifying information
7780
Loop HeaderOptional
Max 1
To indicate that the next segment begins a loop
AMT Loop
Repeat >1
7800
Monetary Amount InformationMandatory
Max 1
To indicate the total monetary amount
7850
Party IdentificationOptional
Max 1
To identify a party by type of organization, name, and code
The N1 segment is used to identify payees or payers.
7900
Party LocationOptional
Max 2
To specify the location of the named party
7950
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
8000
Item IdentificationOptional
Max 2
To specify basic item identification data
8050
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
8100
Quantity InformationOptional
Max >1
To specify quantity information
8150
Message TextOptional
Max >1
To provide a free-form format that allows the transmission of text information
AM1 Loop
Repeat >1
8155
Informational ValuesMandatory
Max 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.
INV Loop
Repeat >1
8160
Investment Vehicle SelectionMandatory
Max 1
To specify type of investment vehicle or account and other basic data about the investment
8165
Quantity InformationOptional
Max >1
To specify quantity information
8170
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
8175
Rate Amounts or PercentsOptional
Max >1
To identify rate amounts or percents for a specific cost or other line item
8190
Loop TrailerOptional
Max 1
To indicate that the loop immediately preceding this segment is complete
K2 Loop
Repeat >1
8200
Administrative MessageMandatory
Max 1
To transmit information in a free-form format for comment or special instruction
8250
Date or Time or PeriodOptional
Max 1
To specify any or all of a date, a time, or a time period
8300
Individual or Organizational NameOptional
Max 1
To supply the full name of an individual or organizational entity
The NM1 segment identifies the originator of the administrative message.
8350
Transaction Set TrailerMandatory
Max 1
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.