Alleged/Responsible Insurance Company Information
Insurance Company Information
Trustee Information
{
"rules": {
"trustInformation.zip": {
"zipcodeUS": 1
},
"trustInformation.phone": {
"phoneUS": 1
},
"trustInformation.dateOfEstablishment": {
"datePresentTo1900": 1
}
}
}
Trust Information
{
"rules": {
"annuity.establishmentDate": {
"datePresentTo1900": 1
},
"annuity.dateFirstPayment": {
"dateAfterOtherOrFuture": "#annuity-date-established"
},
"annuity.dateLastPayment": {
"dateAfterOtherOrFuture": "#annuity-first-payment-date"
}
},
"messages": {
"annuity.dateFirstPayment": {
"dateAfterOtherOrFuture": "Please enter a date after the date established"
},
"annuity.dateLastPayment": {
"dateAfterOtherOrFuture": "Please enter a date after the first payment date and before 12/31/2099"
}
}
}
Annuity Information
{
"rules": {
"plaintiffAttorney.zip": {
"zipcodeUS": 1
},
"plaintiffAttorney.phone": {
"phoneUS": 1
},
"plaintiffAttorney.fax": {
"phoneUS": 1
},
"plaintiffAttorney.email": {
"email": 1
},
"plaintiffAttorney.confirmEmail": {
"equalTo": "#thirdPartyAdmin-email"
},
"plaintiffAttorney.attorneyRepresented": {
"require_from_group": [1, ".attorney-firm-group"]
},
"plaintiffAttorney.firmRepresented": {
"require_from_group": [1, ".attorney-firm-group"]
}
},
"messages": {
"plaintiffAttorney.email": {
"email": "Must be a valid Email Address"
},
"plaintiffAttorney.confirmEmail": {
"equalTo": "Confirm Email Must Match Email"
},
"plaintiffAttorney.fax": {
"phoneUS": "Please enter a properly formatted fax number"
}
}
}
Third Party Administrator Information
{
"rules": {
"caseUpdate.beneficiaryID": {
"number": 1,
"minlength": 10
},
"caseUpdate.dateOfBirth": {
"datePresentTo1900": 1
},
"caseUpdate.incidentDate": {
"dateAfterOther": "#case-update-dob"
}
},
"messages": {
"caseUpdate.beneficiaryID": {
"minlength": "Must be empty or a 10 character Medicaid Member ID",
"number": "Must be empty or a 10 character Medicaid Member ID"
},
"caseUpdate.incidentDate": {
"dateAfterOther": "May not be prior to Date of Birth"
}
}
}
Existing Case Medicaid Member Information
{
"rules": {
"caseUpdate.beneficiaryID": {
"number": 1,
"minlength": 10
},
"caseUpdate.dateOfBirth": {
"datePresentTo1900": 1
},
"caseUpdate.incidentDate": {
"dateAfterOther": "#case-update-dob"
}
},
"messages": {
"caseUpdate.beneficiaryID": {
"minlength": "Must be empty or a 10 character Medicaid Member ID",
"number": "Must be empty or a 10 character Medicaid Member ID"
},
"caseUpdate.incidentDate": {
"dateAfterOther": "May not be prior to Date of Birth"
}
}
}
Estate Existing Case Member
{
"rules": {
"medicaidBeneficiary.zip": {
"zipcodeUS": 1
},
"medicaidBeneficiary.beneficiaryId": {
"number": 1,
"minlength": 10
},
"medicaidBeneficiary.dateOfBirth": {
"datePresentTo1900": 1
},
"medicaidBeneficiary.dateOfDeath": {
"datePresentTo1900": 1,
"dateAfterOther": "#medicaid-beneficiary-date-of-birth"
}
},
"messages": {
"medicaidBeneficiary.dateOfDeath": {
"dateAfterOther": "May not be prior to Date of Birth"
},
"medicaidBeneficiary.beneficiaryId":{
"minlength": "Must be empty or a 10 character Medicaid Member ID",
"number": "Must be empty or a 10 character Medicaid Member ID"
}
}
}
Medicaid Member Information
{
"rules": {
"medicaidBeneficiary.zip": {
"zipcodeUS": 1
},
"medicaidBeneficiary.beneficiaryId": {
"number": 1,
"minlength": 10
},
"medicaidBeneficiary.dateOfBirth": {
"datePresentTo1900": 1
},
"medicaidBeneficiary.dateOfDeath": {
"datePresentTo1900": 1,
"dateAfterOther": "#medicaid-beneficiary-date-of-birth"
},
"caseInformation.incidentDate": {
"datePresentTo1900": 1,
"dateAfterOther": "#medicaid-beneficiary-date-of-birth",
"dateBeforeOther": "#medicaid-beneficiary-date-of-death"
}
},
"messages": {
"medicaidBeneficiary.dateOfDeath": {
"dateAfterOther": "May not be prior to Date of Birth"
},
"caseInformation.incidentDate": {
"dateAfterOther": "May not be prior to Date of Birth",
"dateBeforeOther": "May not be after Date of Death"
},
"medicaidBeneficiary.beneficiaryId":{
"minlength": "Must be empty or a 10 character Medicaid Member ID",
"number": "Must be empty or a 10 character Medicaid Member ID"
}
}
}
Medicaid Member Information
Contingent Beneficiary
Alleged/Responsible Party
{
"rules": {
"attorneys[0].pNumber": {
"number": 1,
"minlength": 5
},
"attorneys[0].email": {
"email": 1
},
"attorneys[0].confirmEmail": {
"equalTo": "#attorney-email"
},
"attorneys[0].phone": {
"phoneUS": 1
},
"attorneys[0].fax": {
"phoneUS": 1
},
"attorneys[0].zip": {
"zipcodeUS": 1
}
},
"messages": {
"attorneys[0].confirmEmail": {
"equalTo": "Confirm Email Must Match Email"
},
"attorneys[0].fax": {
"phoneUS": "Please enter a properly formatted fax number"
}
}
}
Attorney Information
{
"rules": {
"attorneys[0].pNumber": {
"number": 1,
"minlength": 5
},
"attorneys[0].email": {
"email": 1
},
"attorneys[0].confirmEmail": {
"equalTo": "#attorney-email"
},
"attorneys[0].phone": {
"phoneUS": 1
},
"attorneys[0].fax": {
"phoneUS": 1
},
"attorneys[0].zip": {
"zipcodeUS": 1
}
},
"messages": {
"attorneys[0].confirmEmail": {
"equalTo": "Confirm Email Must Match Email"
},
"attorneys[0].fax": {
"phoneUS": "Please enter a properly formatted fax number"
}
}
}
Attorney Information
{
"rules": {
"plaintiffAttorney.pNumber": {
"number": 1,
"minlength": 5
},
"plaintiffAttorney.email": {
"email": 1
},
"plaintiffAttorney.confirmEmail": {
"equalTo": "#plaintiff-attorney-email"
},
"plaintiffAttorney.phone": {
"phoneUS": 1
},
"plaintiffAttorney.fax": {
"phoneUS": 1
},
"plaintiffAttorney.zip": {
"zipcodeUS": 1
}
},
"messages": {
"plaintiffAttorney.confirmEmail": {
"equalTo": "Confirm Email Must Match Email"
},
"plaintiffAttorney.fax": {
"phoneUS": "Please enter a properly formatted fax number"
}
}
}
Plaintiff Attorney Information
Defense Attorney Information
{
"rules": {
"estateAttorney.pNumber": {
"number": 1,
"minlength": 5
},
"estateAttorney.email": {
"email": 1
},
"estateAttorney.confirmEmail": {
"equalTo": "#estate-attorney-email"
},
"estateAttorney.phone": {
"phoneUS": 1
},
"estateAttorney.fax": {
"phoneUS": 1
},
"estateAttorney.zip": {
"zipcodeUS": 1
}
},
"messages": {
"estateAttorney.confirmEmail": {
"equalTo": "Confirm Email Must Match Email"
},
"estateAttorney.fax": {
"phoneUS": "Please enter a properly formatted fax number"
}
}
}
Attorney for the Estate Information
Attach Document(s)
Please attach any and all documents that TPL might require to properly fulfill your request (e.g. HIPAA, complaint, etc.)
Attach Document(s) (e.g. Death Certificate, Marriage License)
Please attach any and all documents that TPL might require to properly fulfill your request (e.g. HIPAA, complaint, etc.)
Asset Information
{
"rules": {
"otherContacts[0].email": {
"email": 1
},
"otherContacts[0].confirmEmail": {
"email": 1
},
"otherContacts[0].phone": {
"phoneUS": 1
},
"otherContacts[0].zip": {
"minlength": 5,
"zipcodeUS": 1
},
"otherContacts[0].fax": {
"phoneUS": 1
},
"otherContacts[0].confirmEmail": {
"equalTo": "#other-contact-email"
}
},
"messages": {
"otherContacts[0].phone": {
"phoneUS": "Please enter a properly formatted phone number"
},
"otherContacts[0].fax": {
"phoneUS": "Please enter a properly formatted fax number"
},
"otherContacts[0].phoneExt": {
"digits": "Please enter a valid phone extension"
},
"otherContacts[0].confirmEmail": {
"equalTo": "Confirm Email Must Match Email"
}
}
}
Other Contact Information
{
"rules": {
"otherContacts[0].email": {
"email": 1
},
"otherContacts[0].confirmEmail": {
"email": 1
},
"otherContacts[0].phone": {
"phoneUS": 1
},
"otherContacts[0].zip": {
"minlength": 5,
"zipcodeUS": 1
},
"otherContacts[0].fax": {
"phoneUS": 1
},
"otherContacts[0].confirmEmail": {
"equalTo": "#other-contact-email"
}
},
"messages": {
"otherContacts[0].phone": {
"phoneUS": "Please enter a properly formatted phone number"
},
"otherContacts[0].fax": {
"phoneUS": "Please enter a properly formatted fax number"
},
"otherContacts[0].phoneExt": {
"digits": "Please enter a valid phone extension"
},
"otherContacts[0].confirmEmail": {
"equalTo": "Confirm Email Must Match Email"
}
}
}
Other Contact Information
{
"rules": {
"estatePersonalRepresentative.email": {
"email": 1
},
"estatePersonalRepresentative.confirmEmail": {
"email": 1
},
"estatePersonalRepresentative.phone": {
"phoneUS": 1
},
"estatePersonalRepresentative.zip": {
"minlength": 5,
"zipcodeUS": 1
},
"estatePersonalRepresentative.fax": {
"phoneUS": 1
},
"estatePersonalRepresentative.confirmEmail": {
"equalTo": "#estate-personal-representative-email"
}
},
"messages": {
"estatePersonalRepresentative.phone": {
"phoneUS": "Please enter a properly formatted phone number"
},
"estatePersonalRepresentative.fax": {
"phoneUS": "Please enter a properly formatted fax number"
},
"estatePersonalRepresentative.phoneExt": {
"digits": "Please enter a valid phone extension"
},
"estatePersonalRepresentative.confirmEmail": {
"equalTo": "Confirm Email Must Match Email"
}
}
}
Estate Personal Representative
{
"rules": {
"otherContacts[0].email": {
"email": 1
},
"otherContacts[0].confirmEmail": {
"email": 1
},
"otherContacts[0].phone": {
"phoneUS": 1
},
"otherContacts[0].zip": {
"minlength": 5,
"zipcodeUS": 1
},
"otherContacts[0].fax": {
"phoneUS": 1
},
"otherContacts[0].confirmEmail": {
"equalTo": "#other-contact-email"
}
},
"messages": {
"otherContacts[0].phone": {
"phoneUS": "Please enter a properly formatted phone number"
},
"otherContacts[0].fax": {
"phoneUS": "Please enter a properly formatted fax number"
},
"otherContacts[0].phoneExt": {
"digits": "Please enter a valid phone extension"
},
"otherContacts[0].confirmEmail": {
"equalTo": "Confirm Email Must Match Email"
}
}
}
Estate Other Contact
{
"rules":{
"medicaidBeneficiary.zip":{
"zipcodeUS":1
},
"medicaidBeneficiary.beneficiaryId":{
"number":1,
"minlength":10
},
"medicaidBeneficiary.dateOfBirth":{
"datePresentTo1900":1
},
"medicaidBeneficiary.dateOfDeath":{
"datePresentTo1900":1,
"dateAfterOther":"#medicaid-beneficiary-date-of-birth"
}
},
"messages":{
"medicaidBeneficiary.dateOfDeath":{
"dateAfterOther":"May not be prior to Date of Birth"
},
"medicaidBeneficiary.beneficiaryId":{
"minlength":"Must be empty or a 10 character Medicaid Member ID",
"number":"Must be empty or a 10 character Medicaid Member ID"
}
}
}