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EDI 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
  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. N1 Loop Mandatory
    Repeat >1
    1. To identify a party by type of organization, name, and code

      The N1 loop repeats for each company or intermediate distributor.
    2. To specify additional names

    3. To specify the location of the named party

    4. To specify the geographic place of the named party

    5. To transmit identifying information as specified by the Reference Identification Qualifier

    6. To specify pertinent dates and times

    7. 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. To identify 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. To identify 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. To indicate that the next segment begins a loop

          4. 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

          5. To indicate that the loop immediately preceding this segment is complete

      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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