The “Insured’s Address” is the insured’s permanent residence, which may be different from the patient’s address in Item Number 5.

INSTRUCTIONS: Enter the insured’s address. If Item Number 4 is completed, then this field should be completed. The first line is for the street address; the second line, the city and state; the third line, the ZIP code.

Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Report a 5 or 9-digit ZIP code. Enter the 9-digit ZIP code without the hyphen.

If reporting a foreign address, contact payer for specific reporting instructions.

“Insured’s Telephone” does not exist in 5010A1. The NUCC recommends that the phone number not be reported. Phone extensions are not supported.

FOR WORKERS COMPENSATION CLAIMS: Enter the address of the Employer.

FOR OTHER PROPERTY AND CASUALTY CLAIMS: Enter the address of the insured noted in Item Number 4.

FOR WORKERS’ COMPENSATION AND OTHER PROPERTY AND CASUALTY CLAIMS: If required by a payer to report a telephone number, do not use a hyphen or space as a separator within the telephone number.

MEDICARE - Enter the insured's address and telephone number. When the address is the same as the patient's, enter the word SAME. Complete this item only when items 4, 6, and 11 are completed.