EDI 267 Individual Life, Annuity and Disability Application

Functional Group IL

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

1. 010 · ST · Transaction Set Header · Max 1 · Mandatory

   To indicate the start of a transaction set and to assign a control number

2. 020 · BGN · Beginning Segment · Max 1 · Mandatory

   To indicate the beginning of a transaction set

3. 030 · DTP · Date or Time or Period · Max >1 · Optional

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

4. NM1 Loop Optional Repeat >1

   1. 040 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

      To supply the full name of an individual or organizational entity

   2. 050 · N3 · Address Information · Max 3 · Optional

      To specify the location of the named party

   3. 060 · N4 · Geographic Location · Max 1 · Optional

      To specify the geographic place of the named party

   4. 070 · REF · Reference Identification · Max 9 · Optional

      To specify identifying information

   5. 080 · PER · Administrative Communications Contact · Max 3 · Optional

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

Detail

1. ACT Loop Mandatory Repeat >1

   1. 005 · ACT · Account Identification · Max 1 · Mandatory

      To specify account information

      The ACT loop repeats for each individual application.

   2. 010 · ASI · Action or Status Indicator · Max 1 · Optional

      To indicate the action to be taken with the information provided or the status of the entity described

   3. 015 · PER · Administrative Communications Contact · Max >1 · Optional

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

   4. 020 · C3 · Currency · Max 1 · Optional

      To specify the currency being used in the transaction set

   5. 025 · LUI · Language Use · Max >1 · Optional

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

   6. 030 · DTP · Date or Time or Period · Max >1 · Optional

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

   7. 035 · BLI · Baseline Item Data · Max 1 · Optional

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

   8. 040 · LIN · Item Identification · Max >1 · Optional

      To specify basic item identification data

   9. 045 · N4 · Geographic Location · Max >1 · Optional

      To specify the geographic place of the named party

   10. 050 · AM1 · Informational Values · Max >1 · Optional

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

   11. 055 · AMT · Monetary Amount · Max >1 · Optional

       To indicate the total monetary amount

   12. 060 · YNQ · Yes/No Question · Max >1 · Optional

       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.

   13. 065 · REF · Reference Identification · Max >1 · Optional

       To specify identifying information

   14. SI Loop Optional Repeat >1

       1. 070 · SI · Service Characteristic Identification · Max 1 · Mandatory

          To specify service characteristic data

          The SI loop is used to report policy options being exercised.

       2. 075 · AMT · Monetary Amount · Max >1 · Optional

          To indicate the total monetary amount

       3. 080 · DTP · Date or Time or Period · Max >1 · Optional

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

       4. 085 · REF · Reference Identification · Max >1 · Optional

          To specify identifying information

       5. 090 · NM1 · Individual or Organizational Name · Max 1 · Optional

          To supply the full name of an individual or organizational entity

       6. 095 · N4 · Geographic Location · Max 1 · Optional

          To specify the geographic place of the named party

       7. 100 · MSG · Message Text · Max >1 · Optional

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

   15. PID Loop Optional Repeat >1

       1. 105 · PID · Product/Item Description · Max 1 · Mandatory

          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. 110 · BLI · Baseline Item Data · Max 1 · Optional

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

       3. 115 · SPA · Status of Product or Activity · Max 1 · Optional

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

       4. 120 · UD · Underwriting Status · Max 1 · Optional

          To identify and describe underwriting status of submitted applications

       5. 125 · AMT · Monetary Amount · Max >1 · Optional

          To indicate the total monetary amount

       6. 130 · AM1 · Informational Values · Max >1 · Optional

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

       7. 135 · PDL · Payment Details · Max >1 · Optional

          To transmit information required to establish payment or remittance activity

       8. 140 · QTY · Quantity · Max >1 · Optional

          To specify quantity information

       9. 145 · DTP · Date or Time or Period · Max >1 · Optional

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

       10. 150 · MSG · Message Text · Max >1 · Optional

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

       11. INV Loop Optional Repeat >1

           1. 155 · INV · Investment Vehicle Selection · Max 1 · Mandatory

              To specify type of investment vehicle or account and other basic data about the investment

           2. 160 · AM1 · Informational Values · Max >1 · Optional

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

           3. 165 · DTP · Date or Time or Period · Max >1 · Optional

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

           4. 170 · QTY · Quantity · Max >1 · Optional

              To specify quantity information

           5. 175 · LIN · Item Identification · Max 2 · Optional

              To specify basic item identification data

           6. 180 · RPA · Rate Amounts or Percents · Max >1 · Optional

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

       12. BEN Loop Optional Repeat >1

           1. 185 · BEN · Beneficiary or Owner Information · Max 1 · Mandatory

              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. 190 · NM1 · Individual or Organizational Name · Max 1 · Optional

              To supply the full name of an individual or organizational entity

           3. 195 · N2 · Additional Name Information · Max 3 · Optional

              To specify additional names or those longer than 35 characters in length

           4. 200 · N3 · Address Information · Max 3 · Optional

              To specify the location of the named party

           5. 205 · N4 · Geographic Location · Max 1 · Optional

              To specify the geographic place of the named party

           6. 210 · REF · Reference Identification · Max >1 · Optional

              To specify identifying information

           7. 215 · DTP · Date or Time or Period · Max >1 · Optional

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

           8. 220 · III · Information · Max >1 · Optional

              To report information

           9. 225 · QTY · Quantity · Max >1 · Optional

              To specify quantity information

           10. 230 · LUI · Language Use · Max 1 · Optional

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

           11. 235 · MSG · Message Text · Max >1 · Optional

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

   16. ENT Loop Optional Repeat >1

       1. 240 · ENT · Entity · Max 1 · Mandatory

          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. 245 · REF · Reference Identification · Max >1 · Optional

          To specify identifying information

       3. 250 · LIN · Item Identification · Max 9 · Optional

          To specify basic item identification data

       4. 255 · DMG · Demographic Information · Max 1 · Optional

          To supply demographic information

       5. 260 · DMA · Additional Demographic Information · Max 1 · Optional

          To supply additional demographic identification

       6. 265 · LUI · Language Use · Max 1 · Optional

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

       7. 270 · DTP · Date or Time or Period · Max >1 · Optional

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

       8. 275 · AM1 · Informational Values · Max >1 · Optional

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

       9. 280 · YNQ · Yes/No Question · Max >1 · Optional

          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.

       10. 285 · QTY · Quantity · Max >1 · Optional

           To specify quantity information

       11. 290 · MSG · Message Text · Max >1 · Optional

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

       12. NM1 Loop Optional Repeat >1

           1. 295 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

              To supply the full name of an individual or organizational entity

              The NM1 loop identifies the entity.

           2. 300 · N2 · Additional Name Information · Max 3 · Optional

              To specify additional names or those longer than 35 characters in length

           3. 305 · REF · Reference Identification · Max >1 · Optional

              To specify identifying information

           4. N3 Loop Optional Repeat >1

              1. 310 · N3 · Address Information · Max 1 · Mandatory

                 To specify the location of the named party

              2. 315 · N4 · Geographic Location · Max 1 · Optional

                 To specify the geographic place of the named party

              3. 320 · COM · Communication Contact Information · Max 9 · Optional

                 To specify a communication contact number

              4. 325 · DTP · Date or Time or Period · Max >1 · Optional

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

       13. LQ Loop Optional Repeat >1

           1. 330 · LQ · Industry Code · Max 1 · Mandatory

              Code to transmit standard industry codes

              The LQ loop reports underwriting requirements.

           2. 335 · SPA · Status of Product or Activity · Max 1 · Optional

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

           3. 340 · DTP · Date or Time or Period · Max >1 · Optional

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

           4. 345 · MSG · Message Text · Max >1 · Optional

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

           5. NM1 Loop Optional Repeat >1

              1. 350 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

                 To supply the full name of an individual or organizational entity

                 The NM1 loop identifies information sources for underwriting requirements.

              2. 355 · N3 · Address Information · Max 3 · Optional

                 To specify the location of the named party

              3. 360 · N4 · Geographic Location · Max 1 · Optional

                 To specify the geographic place of the named party

              4. 365 · REF · Reference Identification · Max >1 · Optional

                 To specify identifying information

              5. 370 · COM · Communication Contact Information · Max 3 · Optional

                 To specify a communication contact number

              6. 375 · LUI · Language Use · Max 1 · Optional

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

              7. 380 · DTP · Date or Time or Period · Max >1 · Optional

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

              8. 385 · MSG · Message Text · Max >1 · Optional

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

       14. BEN Loop Optional Repeat >1

           1. 390 · BEN · Beneficiary or Owner Information · Max 1 · Mandatory

              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. 395 · NM1 · Individual or Organizational Name · Max 1 · Optional

              To supply the full name of an individual or organizational entity

           3. 400 · N2 · Additional Name Information · Max 3 · Optional

              To specify additional names or those longer than 35 characters in length

           4. 405 · N3 · Address Information · Max 3 · Optional

              To specify the location of the named party

           5. 410 · N4 · Geographic Location · Max 1 · Optional

              To specify the geographic place of the named party

           6. 415 · REF · Reference Identification · Max >1 · Optional

              To specify identifying information

           7. 420 · DTP · Date or Time or Period · Max >1 · Optional

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

           8. 425 · III · Information · Max >1 · Optional

              To report information

           9. 430 · QTY · Quantity · Max >1 · Optional

              To specify quantity information

           10. 435 · LUI · Language Use · Max 1 · Optional

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

           11. 440 · MSG · Message Text · Max >1 · Optional

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

       15. PID Loop Optional Repeat >1

           1. 445 · PID · Product/Item Description · Max 1 · Mandatory

              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. 450 · BLI · Baseline Item Data · Max 9 · Optional

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

           3. 455 · SPA · Status of Product or Activity · Max 1 · Optional

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

           4. 460 · AMT · Monetary Amount · Max >1 · Optional

              To indicate the total monetary amount

           5. 465 · QTY · Quantity · Max >1 · Optional

              To specify quantity information

           6. 470 · DTP · Date or Time or Period · Max >1 · Optional

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

           7. 475 · MSG · Message Text · Max >1 · Optional

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

           8. PDL Loop Optional Repeat >1

              1. 480 · PDL · Payment Details · Max 1 · Mandatory

                 To transmit information required to establish payment or remittance activity

              2. 485 · REF · Reference Identification · Max >1 · Optional

                 To specify identifying information

           9. INV Loop Optional Repeat >1

              1. 490 · INV · Investment Vehicle Selection · Max 1 · Mandatory

                 To specify type of investment vehicle or account and other basic data about the investment

              2. 495 · AM1 · Informational Values · Max >1 · Optional

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

              3. 500 · DTP · Date or Time or Period · Max >1 · Optional

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

              4. 505 · RPA · Rate Amounts or Percents · Max >1 · Optional

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

           10. BEN Loop Optional Repeat >1

               1. 510 · BEN · Beneficiary or Owner Information · Max 1 · Mandatory

                  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. 515 · NM1 · Individual or Organizational Name · Max 1 · Optional

                  To supply the full name of an individual or organizational entity

               3. 520 · N2 · Additional Name Information · Max 3 · Optional

                  To specify additional names or those longer than 35 characters in length

               4. 525 · N3 · Address Information · Max 3 · Optional

                  To specify the location of the named party

               5. 530 · N4 · Geographic Location · Max 1 · Optional

                  To specify the geographic place of the named party

               6. 535 · REF · Reference Identification · Max >1 · Optional

                  To specify identifying information

               7. 540 · DTP · Date or Time or Period · Max >1 · Optional

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

               8. 545 · III · Information · Max >1 · Optional

                  To report information

               9. 550 · QTY · Quantity · Max >1 · Optional

                  To specify quantity information

               10. 555 · LUI · Language Use · Max 1 · Optional

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

               11. 560 · MSG · Message Text · Max >1 · Optional

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

       16. UC Loop Optional Repeat >1

           1. 565 · UC · Underwriting Category · Max 1 · Mandatory

              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. 570 · HL · Hierarchical Level · Max 1 · Mandatory

                 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. 575 · UQS · Underwriting Question · Max 1 · Optional

                 To report information provider underwriting data in a question and answer format

              3. 580 · YNQ · Yes/No Question · Max >1 · Optional

                 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. 585 · NM1 · Individual or Organizational Name · Max 1 · Optional

                 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. 590 · N3 · Address Information · Max 3 · Optional

                 To specify the location of the named party

              6. 595 · N4 · Geographic Location · Max 1 · Optional

                 To specify the geographic place of the named party

              7. 600 · COM · Communication Contact Information · Max 9 · Optional

                 To specify a communication contact number

              8. 605 · DTP · Date or Time or Period · Max >1 · Optional

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

              9. 610 · QTY · Quantity · Max >1 · Optional

                 To specify quantity information

              10. 615 · MSG · Message Text · Max >1 · Optional

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

              11. 620 · AM1 · Informational Values · Max >1 · Optional

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

              12. 625 · AMT · Monetary Amount · Max >1 · Optional

                  To indicate the total monetary amount

              13. 630 · III · Information · Max >1 · Optional

                  To report information

              14. 635 · EC · Employment Class · Max 1 · Optional

                  To provide class of employment information

              15. 640 · EMS · Employment Position · Max 1 · Optional

                  To describe employment position

              16. 645 · EMP · Employer · Max 1 · Optional

                  To provide employment specifics

              17. 650 · PCT · Percent Amounts · Max >1 · Optional

                  To qualify percent amounts and supply percent amounts

              18. 655 · SOI · Source of Income · Max >1 · Optional

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

              19. 660 · LIN · Item Identification · Max 2 · Optional

                  To specify basic item identification data

              20. 665 · REF · Reference Identification · Max >1 · Optional

                  To specify identifying information

              21. 670 · ASL · Asset Liability · Max >1 · Optional

                  To report financial information

              22. 675 · TOA · Type of Activity · Max >1 · Optional

                  To specify type of activity information

              23. 680 · TOV · Vehicle Use Information · Max >1 · Optional

                  To report usage of a vehicle

              24. 685 · VEH · Vehicle Information · Max >1 · Optional

                  To provide descriptions that identify a specific vehicle

              25. 690 · CDS · Case Description · Max >1 · Optional

                  To identify and describe a specific court case

              26. 695 · CED · Administration of Justice Event Description · Max >1 · Optional

                  To describe specific administration of justice events and actions

              27. 700 · SIN · Substance Use · Max >1 · Optional

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

              28. 705 · UCS · Underwriting Considerations · Max >1 · Optional

                  To report personal health and medical history data

              29. 710 · FH · Family History · Max >1 · Optional

                  To report information about a person's family health history

              30. 715 · SPA · Status of Product or Activity · Max 1 · Optional

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

              31. 720 · MPI · Military Personnel Information · Max 1 · Optional

                  To report military service data

   17. PWK Loop Optional Repeat >1

       1. 725 · PWK · Paperwork · Max 1 · Mandatory

          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. 730 · NM1 · Individual or Organizational Name · Max 1 · Optional

          To supply the full name of an individual or organizational entity

          The NM1 segment identifies the person completing or signing a form.

       3. 735 · N4 · Geographic Location · Max 1 · Optional

          To specify the geographic place of the named party

       4. 740 · REF · Reference Identification · Max >1 · Optional

          To specify identifying information

       5. 745 · DTP · Date or Time or Period · Max >1 · Optional

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

       6. 750 · SPA · Status of Product or Activity · Max 1 · Optional

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

       7. EFI Loop Optional Repeat >1

          1. 755 · EFI · Electronic Format Identification · Max 1 · Mandatory

             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. 760 · BIN · Binary Data · Max 1 · Mandatory

             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

   18. LX Loop Optional Repeat >1

       1. 765 · LX · Assigned Number · Max 1 · Mandatory

          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. 770 · PDL · Payment Details · Max 1 · Mandatory

             To transmit information required to establish payment or remittance activity

          2. 775 · REF · Reference Identification · Max >1 · Optional

             To specify identifying information

          3. AMT Loop Optional Repeat >1

             1. 780 · AMT · Monetary Amount · Max 1 · Mandatory

                To indicate the total monetary amount

             2. 785 · N1 · Name · Max 1 · Optional

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

                The N1 segment is used to identify payees or payers.

             3. 790 · N3 · Address Information · Max 2 · Optional

                To specify the location of the named party

             4. 795 · N4 · Geographic Location · Max 1 · Optional

                To specify the geographic place of the named party

             5. 800 · LIN · Item Identification · Max 2 · Optional

                To specify basic item identification data

             6. 805 · DTP · Date or Time or Period · Max >1 · Optional

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

             7. 810 · QTY · Quantity · Max >1 · Optional

                To specify quantity information

             8. 815 · MSG · Message Text · Max >1 · Optional

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

   19. K2 Loop Optional Repeat >1

       1. 820 · K2 · Administrative Message · Max 1 · Mandatory

          To transmit information in a free-form format for comment or special instruction

       2. 825 · DTP · Date or Time or Period · Max 1 · Optional

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

       3. 830 · NM1 · Individual or Organizational Name · Max 1 · Optional

          To supply the full name of an individual or organizational entity

          The NM1 segment identifies the originator of the administrative message.

2. 835 · SE · Transaction Set Trailer · Max 1 · Mandatory

   To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)