       01  PATIENT-INSURANCE.                                                   
           05  INS-COMPANY-PRIMARY.                                             
               10  PATIENT-ID              PIC X(6).                            
               10  INS-COMPANY-PRIMARY-ID  PIC X(8).                            
               10  CARRIER-NAME            PIC X(30).                           
               10  CARRIER-PHONE           PIC X(10).                           
               10  CARRIER-FAX             PIC X(10).                           
               10  INSURED-NAME            PIC X(30).                           
               10  INSURED-GENDER          PIC X(01).                           
                   88  FEMALE          VALUE "F".                               
                   88  MALE            VALUE "M".                               
                   88  NOT-PROVIDED    VALUE "N".                               
                   88 VALID-GENDER                                              
                       VALUES ARE "F", "M", "N".                                
               10  PATIENT-RELATIONSHIP    PIC X(02).                           
                   88  SPOUSE          VALUE "SP".                              
                   88  SELF-REL        VALUE "SE".                              
                   88  CHILD           VALUE "CH".                              
                   88  OTHER-REL       VALUE "OT".                              
                   88 VALID-RELS                                                
                       VALUES ARE "SP", "SE", "SP", "OT".                       
               10  INS-IDENT-NBR           PIC X(20).                           
               10  GROUP-NBR               PIC X(10).                           
               10  ADDRESS-CLAIMS.                                              
                   15  STREET              PIC X(30).                           
                   15  CITY                PIC X(20).                           
                   15  STATE               PIC X(02).                           
                   15  ZIP                 PIC X(9).                            
               10  RETIRED-IND    PIC X(01).                                    
                   88 RETIRED          VALUE "Y".                               
                   88 NOT-RETIRED      VALUE "N".                               
                   88 VALID-RET-IND  VALUES ARE "Y", "N".                       
           05  INS-COMPANY-SECONDARY.                                           
               10  CARRIER-ID              PIC X(8).                            
               10  CARRIER-NAME            PIC X(30).                           
               10  CARRIER-PHONE           PIC X(10).                           
               10  CARRIER-FAX             PIC X(10).                           
               10  INSUREDS-NAME           PIC X(30).                           
               10  PATIENT-RELATIONSHIP    PIC X(02).                           
                   88  SPOUSE          VALUE "SP".                              
                   88  SELF-REL        VALUE "SE".                              
                   88  CHILD           VALUE "CH".                              
                   88  OTHER-REL       VALUE "OT".                              
                   88 VALID-RELS                                                
                       VALUES ARE "SP", "SE", "SP", "OT".                       
               10  INS-IDENT-NBR           PIC X(20).                           
               10  GROUP-NBR               PIC X(10).                           
               10  ADDRESS-CLAIMS.                                              
                   15  STREET              PIC X(30).                           
                   15  CITY                PIC X(20).                           
                   15  STATE               PIC X(02).                           
                   15  ZIP                 PIC X(9).                            
           05  BENEFIT-ASSIGNMENT-DETAILS.                                      
               10  MEDICARE-BENEFICIARY    PIC X(30).                           
               10  MEDICARE-CLAIM-NBR      PIC X(15).                           
               10  COMMERCIAL-BENEFICIARY  PIC X(30).                           
               10  COMMERCIAL-CLAIM-NBR    PIC X(15).                           
           05  PAT-INSURANCE-COMMENTS      PIC X(100).                          
           05  FILLER                      PIC X(142).                          
