| Name | Description | Type | Additional information |
|---|---|---|---|
| HomeCountry | string |
None. |
|
| HomeCityandState | string |
None. |
|
| TreatmentCountry | string |
None. |
|
| TreatmentCityandState | string |
None. |
|
| PolicyHolderName | string |
None. |
|
| DateofAccident | string |
None. |
|
| AccidentOccuredDetails | string |
None. |
|
| AccidentPlace | string |
None. |
|
| IsAnyOtherPersonResponsible | string |
None. |
|
| IfyesExplainOtherPerson | string |
None. |
|
| InfluenceOfDrugs | string |
None. |
|
| IsSportsRelated | string |
None. |
|
| SportsType | string |
None. |
|
| CollegiateSportsProgram | string |
None. |
|
| IsOtherInsurance | string |
None. |
|
| OtherInsurance | Insurance |
None. |
|
| DateSigned | string |
None. |
|
| PatientSignature | string |
None. |
|
| AccidentOccurDate | string |
None. |
|
| AccidentOccurTime | string |
None. |
|
| Title | string |
None. |
|
| FirstName | string |
None. |
|
| LastName | string |
None. |
|
| MiddleName | string |
None. |
|
| string |
None. |
||
| Alias | string |
None. |
|
| DOB | string |
None. |
|
| GBGID | string |
None. |
|
| EmployerName | string |
None. |
|
| Address | string |
None. |
|
| City | string |
None. |
|
| Country | string |
None. |
|
| Phonenumber | string |
None. |
|
| Gender | string |
None. |
|
| State | string |
None. |
|
| AlternatePhone | string |
None. |
|
| ZipCode | string |
None. |
|
| MobileNumber | string |
None. |