To record information specific to the primary insured and the insurance carrier for that insured
| Position | Element | Name | Type | Min/Max | Repeat | |
|---|---|---|---|---|---|---|
| 1 | 1138 | Payer Responsibility Sequence Number Code | Mandatory | ID | 1/1 | 1 |
| 2 | 1069 | Individual Relationship Code | Opt | ID | 2/2 | 1 |
| 3 | 127 | Reference Identification | Opt | Alphanumeric | 1/80 | 1 |
| 4 | 93 | Name | Opt | Alphanumeric | 1/60 | 1 |
| 5 | 1336 | Insurance Type Code | Opt | ID | 1/3 | 1 |
| 6 | 1143 | Coordination of Benefits Code | Opt | ID | 1/1 | 1 |
| 7 | 1073 | Yes/No Condition or Response Code | Opt | ID | 1/1 | 1 |
| 8 | 584 | Employment Status Code | Opt | ID | 2/2 | 1 |
| 9 | 1032 | Claim Filing Indicator Code | Opt | ID | 1/2 | 1 |
| 10 | 1732 | Source of Payment Typology Code | Opt | ID | 2/6 | 1 |