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Transaction Set
in
X12 Release 004030

267 Individual Life, Annuity and Disability Application

Functional Group AD

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
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 Period
Max >1
To specify any or all of a date, a time, or a time period
NM1 Loop
Repeat >1
0400
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
0500
Address Information
Max 3
To specify the location of the named party
0600
Geographic Location
Max 1
To specify the geographic place of the named party
0700
Reference Identification
Max 9
To specify identifying information
0800
Administrative Communications Contact
Max 3
To identify a person or office to whom administrative communications should be directed

Detail

Sequence
Segment
Name
Max use
N1 Loop
Repeat >1
0010
NameMandatory
Max 1
To identify a party by type of organization, name, and code
The N1 loop repeats for each company or intermediate distributor.
0015
Additional Name Information
Max 3
To specify additional names
0020
Address Information
Max 3
To specify the location of the named party
0025
Geographic Location
Max 1
To specify the geographic place of the named party
0030
Reference Identification
Max >1
To transmit identifying information as specified by the Reference Identification Qualifier
0040
Date/Time Reference
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 Indicator
Max 1
To indicate the action to be taken with the information provided or the status of the entity described
0150
Administrative Communications Contact
Max >1
To identify a person or office to whom administrative communications should be directed
0200
Currency
Max 1
To specify the currency being used in the transaction set
0250
Language Use
Max >1
To specify language, type of usage, and proficiency or fluency
0300
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
0350
Baseline Item Data
Max 1
To specify basic item data: item identification, quantity, and price
0400
Item Identification
Max >1
To specify basic item identification data
0450
Payment Details
Max >1
To transmit information required to establish payment or remittance activity
0500
Informational Values
Max >1
To specify a code and the amount or quantity or percentage associated with it
0550
Monetary Amount
Max >1
To indicate the total monetary amount
0575
Quantity
Max >1
To specify quantity information
0600
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.
0650
Reference Identification
Max >1
To specify identifying information
LQ Loop
Repeat >1
0660
Industry Code
Max 1
Code to transmit standard industry codes
The LQ loop is used to report jurisdictional information about the application.
0670
Geographic Location
Max >1
To specify the geographic place of the named party
0680
Language Use
Max >1
To specify language, type of usage, and proficiency or fluency
SI Loop
Repeat >1
0700
Service Characteristic Identification
Max 1
To specify service characteristic data
The SI loop is used to report policy options being exercised.
0750
Monetary Amount
Max >1
To indicate the total monetary amount
0800
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
0850
Reference Identification
Max >1
To specify identifying information
0900
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
0950
Geographic Location
Max 1
To specify the geographic place of the named party
1000
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
PID Loop
Repeat >1
1050
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.
1100
Baseline Item Data
Max 1
To specify basic item data: item identification, quantity, and price
1150
Status of Product or Activity
Max 1
To indicate the details and status of a product or product activity
1200
Underwriting Status
Max 1
To identify and describe underwriting status of submitted applications
1250
Monetary Amount
Max >1
To indicate the total monetary amount
1300
Informational Values
Max >1
To specify a code and the amount or quantity or percentage associated with it
1350
Payment Details
Max >1
To transmit information required to establish payment or remittance activity
1400
Quantity
Max >1
To specify quantity information
1450
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
1500
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
INV Loop
Repeat >1
1550
Investment Vehicle Selection
Max 1
To specify type of investment vehicle or account and other basic data about the investment
1600
Informational Values
Max >1
To specify a code and the amount or quantity or percentage associated with it
1650
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
1700
Quantity
Max >1
To specify quantity information
1750
Item Identification
Max 2
To specify basic item identification data
1800
Rate Amounts or Percents
Max >1
To identify rate amounts or percents for a specific cost or other line item
BEN Loop
Repeat >1
1850
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.
1900
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
1950
Additional Name Information
Max 3
To specify additional names
2000
Address Information
Max 3
To specify the location of the named party
2050
Geographic Location
Max 1
To specify the geographic place of the named party
2100
Reference Identification
Max >1
To specify identifying information
2150
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
2200
Information
Max >1
To report information
2250
Quantity
Max >1
To specify quantity information
2270
Monetary Amount
Max >1
To indicate the total monetary amount
2300
Language Use
Max 1
To specify language, type of usage, and proficiency or fluency
2350
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
ENT Loop
Repeat >1
2400
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.
2410
Property or Entity Identification
Max 2
To define the attributes of a property or an entity
2450
Reference Identification
Max >1
To specify identifying information
2500
Item Identification
Max 9
To specify basic item identification data
2550
Demographic Information
Max 1
To supply demographic information
2600
Additional Demographic Information
Max 1
To supply additional demographic identification
2620
Additional Individual Demographic Information
Max 1
To provide additional demographic information to the receiving school, institution, or agency to assist in identifying the particular student
2650
Language Use
Max 1
To specify language, type of usage, and proficiency or fluency
2670
Entity Relationship
Max 1
To identify the explicit relationship between entities, i.e., parent, child, peer
2700
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
2720
Monetary Amount
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 Values
Max >1
To specify a code and the amount or quantity or percentage associated with it
2770
Rate Amounts or Percents
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 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.
2850
Quantity
Max >1
To specify quantity information
2900
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
NM1 Loop
Repeat >1
2950
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
The NM1 loop identifies the entity.
3000
Additional Name Information
Max 3
To specify additional names
3050
Reference Identification
Max >1
To specify identifying information
3070
Informational Values
Max >1
To specify a code and the amount or quantity or percentage associated with it
N3 Loop
Repeat >1
3100
Address Information
Max 1
To specify the location of the named party
3150
Geographic Location
Max 1
To specify the geographic place of the named party
3200
Communication Contact Information
Max 9
To specify a communication contact number
3250
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
3270
Quantity
Max 1
To specify quantity information
LQ Loop
Repeat >1
3300
Industry Code
Max 1
Code to transmit standard industry codes
The LQ loop reports underwriting requirements.
3350
Status of Product or Activity
Max 1
To indicate the details and status of a product or product activity
3400
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
3450
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
NM1 Loop
Repeat >1
3500
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.
3550
Address Information
Max 3
To specify the location of the named party
3600
Geographic Location
Max 1
To specify the geographic place of the named party
3650
Reference Identification
Max >1
To specify identifying information
3700
Communication Contact Information
Max 3
To specify a communication contact number
3750
Language Use
Max 1
To specify language, type of usage, and proficiency or fluency
3800
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
3850
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
BEN Loop
Repeat >1
3900
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.
3950
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
4000
Additional Name Information
Max 3
To specify additional names
4050
Address Information
Max 3
To specify the location of the named party
4100
Geographic Location
Max 1
To specify the geographic place of the named party
4150
Reference Identification
Max >1
To specify identifying information
4200
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
4250
Information
Max >1
To report information
4300
Quantity
Max >1
To specify quantity information
4320
Monetary Amount
Max >1
To indicate the total monetary amount
4350
Language Use
Max 1
To specify language, type of usage, and proficiency or fluency
4400
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
PID Loop
Repeat >1
4450
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.
4500
Baseline Item Data
Max 9
To specify basic item data: item identification, quantity, and price
4550
Status of Product or Activity
Max 1
To indicate the details and status of a product or product activity
4600
Monetary Amount
Max >1
To indicate the total monetary amount
4650
Quantity
Max >1
To specify quantity information
4700
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
4720
Yes/No Question
Max >1
To identify and answer yes and no questions, including the date, time, and comments further qualifying the condition
4750
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
PDL Loop
Repeat >1
4800
Payment Details
Max 1
To transmit information required to establish payment or remittance activity
4850
Reference Identification
Max >1
To specify identifying information
INV Loop
Repeat >1
4900
Investment Vehicle Selection
Max 1
To specify type of investment vehicle or account and other basic data about the investment
4950
Informational Values
Max >1
To specify a code and the amount or quantity or percentage associated with it
5000
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
5050
Rate Amounts or Percents
Max >1
To identify rate amounts or percents for a specific cost or other line item
BEN Loop
Repeat >1
5100
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.
5150
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
5200
Additional Name Information
Max 3
To specify additional names
5250
Address Information
Max 3
To specify the location of the named party
5300
Geographic Location
Max 1
To specify the geographic place of the named party
5350
Reference Identification
Max >1
To specify identifying information
5400
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
5450
Information
Max >1
To report information
5500
Quantity
Max >1
To specify quantity information
5520
Monetary Amount
Max >1
To indicate the total monetary amount
5550
Language Use
Max 1
To specify language, type of usage, and proficiency or fluency
5600
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
UC Loop
Repeat >1
5650
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
5700
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.
5750
Underwriting Question
Max 1
To report information provider underwriting data in a question and answer format
5800
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.
5850
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.
5900
Address Information
Max 3
To specify the location of the named party
5950
Geographic Location
Max 1
To specify the geographic place of the named party
6000
Communication Contact Information
Max 9
To specify a communication contact number
6050
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
6100
Quantity
Max >1
To specify quantity information
6150
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
6200
Informational Values
Max >1
To specify a code and the amount or quantity or percentage associated with it
6250
Monetary Amount
Max >1
To indicate the total monetary amount
6300
Information
Max >1
To report information
6350
Employment Class
Max 1
To provide class of employment information
6400
Employment Position
Max 1
To describe employment position
6450
Employer
Max 1
To provide employment specifics
6500
Percent Amounts
Max >1
To qualify percent amounts and supply percent amounts
6550
Source of Income
Max >1
To define the source and related information about the income being reported
6600
Item Identification
Max 2
To specify basic item identification data
6650
Reference Identification
Max >1
To specify identifying information
6700
Asset Liability
Max >1
To report financial information
6750
Type of Activity
Max >1
To specify type of activity information
6800
Vehicle Use Information
Max >1
To report usage of a vehicle
6850
Vehicle Information
Max >1
To provide descriptions that identify a specific vehicle
6900
Case Description
Max >1
To identify and describe a specific court case
6950
Administration of Justice Event Description
Max >1
To describe specific administration of justice events and actions
7000
Substance Use
Max >1
To report use of tobacco, alcohol, drugs or other substances
7050
Underwriting Considerations
Max >1
To report personal health and medical history data
7100
Family History
Max >1
To report information about a person's family health history
7150
Status of Product or Activity
Max 1
To indicate the details and status of a product or product activity
7200
Military Personnel Information
Max 1
To report military service data
PWK Loop
Repeat >1
7250
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.
7300
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.
7350
Geographic Location
Max 1
To specify the geographic place of the named party
7400
Reference Identification
Max >1
To specify identifying information
7450
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
7500
Status of Product or Activity
Max 1
To indicate the details and status of a product or product activity
EFI Loop
Repeat >1
7550
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.
7600
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
7650
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
7700
Payment Details
Max 1
To transmit information required to establish payment or remittance activity
7750
Reference Identification
Max >1
To specify identifying information
7780
Loop Header
Max 1
To indicate that the next segment begins a loop
AMT Loop
Repeat >1
7800
Monetary Amount
Max 1
To indicate the total monetary amount
7850
Name
Max 1
To identify a party by type of organization, name, and code
The N1 segment is used to identify payees or payers.
7900
Address Information
Max 2
To specify the location of the named party
7950
Geographic Location
Max 1
To specify the geographic place of the named party
8000
Item Identification
Max 2
To specify basic item identification data
8050
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
8100
Quantity
Max >1
To specify quantity information
8150
Message Text
Max >1
To provide a free-form format that allows the transmission of text information
AM1 Loop
Repeat >1
8155
Informational Values
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 Selection
Max 1
To specify type of investment vehicle or account and other basic data about the investment
8165
Quantity
Max >1
To specify quantity information
8170
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
8175
Rate Amounts or Percents
Max >1
To identify rate amounts or percents for a specific cost or other line item
8190
Loop Trailer
Max 1
To indicate that the loop immediately preceding this segment is complete
K2 Loop
Repeat >1
8200
Administrative Message
Max 1
To transmit information in a free-form format for comment or special instruction
8250
Date or Time or Period
Max 1
To specify any or all of a date, a time, or a time period
8300
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.
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.
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.