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Transaction Set
in
X12 Release 004010

267 Individual Life, Annuity and Disability Application

Functional Group IL

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

Sequence
Segment
Name
Max use
010
Transaction Set HeaderMandatory
Max 1
To indicate the start of a transaction set and to assign a control number
020
Beginning SegmentMandatory
Max 1
To indicate the beginning of a transaction set
030
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
NM1 Loop
Repeat >1
040
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
050
Address Information
Max 3
To specify the location of the named party
060
Geographic Location
Max 1
To specify the geographic place of the named party
070
Reference Identification
Max 9
To specify identifying information
080
Administrative Communications Contact
Max 3
To identify a person or office to whom administrative communications should be directed

Detail

Sequence
Segment
Name
Max use
ACT Loop
Repeat >1
005
Account IdentificationMandatory
Max 1
To specify account information
The ACT loop repeats for each individual application.
010
Action or Status Indicator
Max 1
To indicate the action to be taken with the information provided or the status of the entity described
015
Administrative Communications Contact
Max >1
To identify a person or office to whom administrative communications should be directed
020
Currency
Max 1
To specify the currency being used in the transaction set
025
Language Use
Max >1
To specify language, type of usage, and proficiency or fluency
030
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
035
Baseline Item Data
Max 1
To specify basic item data: item identification, quantity, and price
040
Item Identification
Max >1
To specify basic item identification data
045
Geographic Location
Max >1
To specify the geographic place of the named party
050
Informational Values
Max >1
To specify a code and the amount or quantity or percentage associated with it
055
Monetary Amount
Max >1
To indicate the total monetary amount
060
Yes/No Question
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.
065
Reference Identification
Max >1
To specify identifying information
SI Loop
Repeat >1
070
Service Characteristic Identification
Max 1
To specify service characteristic data
The SI loop is used to report policy options being exercised.
075
Monetary Amount
Max >1
To indicate the total monetary amount
080
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
085
Reference Identification
Max >1
To specify identifying information
090
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
095
Geographic Location
Max 1
To specify the geographic place of the named party
100
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
PID Loop
Repeat >1
105
Product/Item Description
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.
110
Baseline Item Data
Max 1
To specify basic item data: item identification, quantity, and price
115
Status of Product or Activity
Max 1
To indicate the details and status of a product or product activity
120
Underwriting Status
Max 1
To identify and describe underwriting status of submitted applications
125
Monetary Amount
Max >1
To indicate the total monetary amount
130
Informational Values
Max >1
To specify a code and the amount or quantity or percentage associated with it
135
Payment Details
Max >1
To transmit information required to establish payment or remittance activity
140
Quantity
Max >1
To specify quantity information
145
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
150
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
INV Loop
Repeat >1
155
Investment Vehicle Selection
Max 1
To specify type of investment vehicle or account and other basic data about the investment
160
Informational Values
Max >1
To specify a code and the amount or quantity or percentage associated with it
165
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
170
Quantity
Max >1
To specify quantity information
175
Item Identification
Max 2
To specify basic item identification data
180
Rate Amounts or Percents
Max >1
To identify rate amounts or percents for a specific cost or other line item
BEN Loop
Repeat >1
185
Beneficiary or Owner Information
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.
190
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
195
Additional Name Information
Max 3
To specify additional names or those longer than 35 characters in length
200
Address Information
Max 3
To specify the location of the named party
205
Geographic Location
Max 1
To specify the geographic place of the named party
210
Reference Identification
Max >1
To specify identifying information
215
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
220
Information
Max >1
To report information
225
Quantity
Max >1
To specify quantity information
230
Language Use
Max 1
To specify language, type of usage, and proficiency or fluency
235
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
ENT Loop
Repeat >1
240
Entity
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.
245
Reference Identification
Max >1
To specify identifying information
250
Item Identification
Max 9
To specify basic item identification data
255
Demographic Information
Max 1
To supply demographic information
260
Additional Demographic Information
Max 1
To supply additional demographic identification
265
Language Use
Max 1
To specify language, type of usage, and proficiency or fluency
270
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
275
Informational Values
Max >1
To specify a code and the amount or quantity or percentage associated with it
280
Yes/No Question
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.
285
Quantity
Max >1
To specify quantity information
290
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
NM1 Loop
Repeat >1
295
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
The NM1 loop identifies the entity.
300
Additional Name Information
Max 3
To specify additional names or those longer than 35 characters in length
305
Reference Identification
Max >1
To specify identifying information
N3 Loop
Repeat >1
310
Address Information
Max 1
To specify the location of the named party
315
Geographic Location
Max 1
To specify the geographic place of the named party
320
Communication Contact Information
Max 9
To specify a communication contact number
325
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
LQ Loop
Repeat >1
330
Industry Code
Max 1
Code to transmit standard industry codes
The LQ loop reports underwriting requirements.
335
Status of Product or Activity
Max 1
To indicate the details and status of a product or product activity
340
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
345
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
NM1 Loop
Repeat >1
350
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
The NM1 loop identifies information sources for underwriting requirements.
355
Address Information
Max 3
To specify the location of the named party
360
Geographic Location
Max 1
To specify the geographic place of the named party
365
Reference Identification
Max >1
To specify identifying information
370
Communication Contact Information
Max 3
To specify a communication contact number
375
Language Use
Max 1
To specify language, type of usage, and proficiency or fluency
380
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
385
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
BEN Loop
Repeat >1
390
Beneficiary or Owner Information
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.
395
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
400
Additional Name Information
Max 3
To specify additional names or those longer than 35 characters in length
405
Address Information
Max 3
To specify the location of the named party
410
Geographic Location
Max 1
To specify the geographic place of the named party
415
Reference Identification
Max >1
To specify identifying information
420
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
425
Information
Max >1
To report information
430
Quantity
Max >1
To specify quantity information
435
Language Use
Max 1
To specify language, type of usage, and proficiency or fluency
440
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
PID Loop
Repeat >1
445
Product/Item Description
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.
450
Baseline Item Data
Max 9
To specify basic item data: item identification, quantity, and price
455
Status of Product or Activity
Max 1
To indicate the details and status of a product or product activity
460
Monetary Amount
Max >1
To indicate the total monetary amount
465
Quantity
Max >1
To specify quantity information
470
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
475
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
PDL Loop
Repeat >1
480
Payment Details
Max 1
To transmit information required to establish payment or remittance activity
485
Reference Identification
Max >1
To specify identifying information
INV Loop
Repeat >1
490
Investment Vehicle Selection
Max 1
To specify type of investment vehicle or account and other basic data about the investment
495
Informational Values
Max >1
To specify a code and the amount or quantity or percentage associated with it
500
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
505
Rate Amounts or Percents
Max >1
To identify rate amounts or percents for a specific cost or other line item
BEN Loop
Repeat >1
510
Beneficiary or Owner Information
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.
515
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
520
Additional Name Information
Max 3
To specify additional names or those longer than 35 characters in length
525
Address Information
Max 3
To specify the location of the named party
530
Geographic Location
Max 1
To specify the geographic place of the named party
535
Reference Identification
Max >1
To specify identifying information
540
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
545
Information
Max >1
To report information
550
Quantity
Max >1
To specify quantity information
555
Language Use
Max 1
To specify language, type of usage, and proficiency or fluency
560
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
UC Loop
Repeat >1
565
Underwriting Category
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
570
Hierarchical Level
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.
575
Underwriting Question
Max 1
To report information provider underwriting data in a question and answer format
580
Yes/No Question
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.
585
Individual or Organizational Name
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.
590
Address Information
Max 3
To specify the location of the named party
595
Geographic Location
Max 1
To specify the geographic place of the named party
600
Communication Contact Information
Max 9
To specify a communication contact number
605
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
610
Quantity
Max >1
To specify quantity information
615
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
620
Informational Values
Max >1
To specify a code and the amount or quantity or percentage associated with it
625
Monetary Amount
Max >1
To indicate the total monetary amount
630
Information
Max >1
To report information
635
Employment Class
Max 1
To provide class of employment information
640
Employment Position
Max 1
To describe employment position
645
Employer
Max 1
To provide employment specifics
650
Percent Amounts
Max >1
To qualify percent amounts and supply percent amounts
655
Source of Income
Max >1
To define the source and related information about the income being reported
660
Item Identification
Max 2
To specify basic item identification data
665
Reference Identification
Max >1
To specify identifying information
670
Asset Liability
Max >1
To report financial information
675
Type of Activity
Max >1
To specify type of activity information
680
Vehicle Use Information
Max >1
To report usage of a vehicle
685
Vehicle Information
Max >1
To provide descriptions that identify a specific vehicle
690
Case Description
Max >1
To identify and describe a specific court case
695
Administration of Justice Event Description
Max >1
To describe specific administration of justice events and actions
700
Substance Use
Max >1
To report use of tobacco, alcohol, drugs or other substances
705
Underwriting Considerations
Max >1
To report personal health and medical history data
710
Family History
Max >1
To report information about a person's family health history
715
Status of Product or Activity
Max 1
To indicate the details and status of a product or product activity
720
Military Personnel Information
Max 1
To report military service data
PWK Loop
Repeat >1
725
Paperwork
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.
730
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
The NM1 segment identifies the person completing or signing a form.
735
Geographic Location
Max 1
To specify the geographic place of the named party
740
Reference Identification
Max >1
To specify identifying information
745
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
750
Status of Product or Activity
Max 1
To indicate the details and status of a product or product activity
EFI Loop
Repeat >1
755
Electronic Format Identification
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.
760
Binary DataMandatory
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
765
Assigned Number
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
770
Payment Details
Max 1
To transmit information required to establish payment or remittance activity
775
Reference Identification
Max >1
To specify identifying information
AMT Loop
Repeat >1
780
Monetary Amount
Max 1
To indicate the total monetary amount
785
Name
Max 1
To identify a party by type of organization, name, and code
The N1 segment is used to identify payees or payers.
790
Address Information
Max 2
To specify the location of the named party
795
Geographic Location
Max 1
To specify the geographic place of the named party
800
Item Identification
Max 2
To specify basic item identification data
805
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
810
Quantity
Max >1
To specify quantity information
815
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
K2 Loop
Repeat >1
820
Administrative Message
Max 1
To transmit information in a free-form format for comment or special instruction
825
Date or Time or Period
Max 1
To specify any or all of a date, a time, or a time period
830
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
The NM1 segment identifies the originator of the administrative message.
835
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.
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.