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FirstName - first_name LastName - last_name DOB - dob Gender - gender Address - street_addr City - city State - state ZipCode - zip Relationship to Insured - insurance.respparty (e.g self, child, spouse, other) // Primary Insurance Fields Primary Insurance - insurance.primary_carrier_code (insurer_id (e.g. car7147) Primary Insurance Group Number - AMD code)insurance.primary_group_number Primary Insurance CoverageSubscriber Number - insurance.respparty (e.g self, child, spouse, other) Group Number - insurance.group_number Subscriber Numberprimary_subscriber_num Primary Insurance Card Front - insurance.primary_card_front Primary Insurance Card Back - insurance.subscriberprimary_card_numback // Secondary Insurance Fields (Optional) Secondary Insurance - insurance.secondary_carrier_code (insurer_id (e.g. car7147 - AMD code) Secondary Insurance Group Number - insurance.secondary_group_number Secondary Insurance Subscriber Number - insurance.secondary_subscriber_num Secondary Insurance Card Front - insurance.secondary_card_front Secondary Insurance Card Back - insurance.secondary_card_back If relationship dependentis (child, spouse, other): Guarantor Name - insurance.guarantor_name Guarantor DOB - insurance.guarantor_dob Guarantor Address1 - insurance.guarantor_address Guarantor City - insurance.guarantor_city Guarantor State - insurance.guarantor_state Guarantor Zip - - insurance.guarantor_zip |
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