Form 1 OCSE Insurance Match Standard Input File Record

OMB Control Number: 0970-0342

Part A: OCSE Insurance Match Standard Input File Record Expiration Date: XX/XX/20XX

1. OCSE Insurance Match Standard Input File Record

The IM SIF is a standard, fixed-format layout used for sending insurance claim data to us. This section explains the SIF record layout, including field definitions and required fields. Although all of the data elements are helpful to state child support agencies, most of the elements are not required. If the information is not available, you must fill the fields with spaces.

Chart A-1 includes the following information:

Field Name Identifies the name of the field.

Location Identifies the position of the field in the record.

Length Identifies the size of the field in bytes.

A/N Designates the type of field: alphabetic (A), numeric (N), or alphanumeric (A/N).

Comments Provides a description of the field, as well as valid values.

Chart A-1: OCSE Insurance Match Standard Input File Record
Field Name	Location	Length	A/N	Comments
Record Identifier	1-2	2	A/N	The characters ‘IM.’
Insurer Processing Date	3-10	8	A/N	The date you created or updated the record in your system. The date is in the CCYYMMDD format.
Insurer Provided SSN	11-19	9	A/N	The claimant’s SSN you have on file. If you cannot provide the SSN, you must provide the Claimant Birth Date or Claimant Address fields.
Obligor SSN	20-28	9	A/N	Matching partners must use the SSN we provided in the Debtor file.
Obligor Last Name	29-48	20	A/N	Matching partners must use the last name we provided in the Debtor file.
Obligor First Name	49-63	15	A/N	Matching partners must use the first name we provided in the Debtor file.
Insurer Identifier	64-72	9	A/N	Your Federal Employer Identification Number.
Insurer Name	73-117	45	A/N	The insurer who keeps the insurance claim and to whom the state is directed to send the insurance intercept request for processing. This field is required.
Insurer Address Line 1	118-157	40	A/N	The insurer’s street address where the state sends the insurance intercept request. This field is required unless Insurer Address Line 2 is provided.
Insurer Address Line 2	158-197	40	A/N	The insurer’s address information where the state sends the insurance intercept request.
Insurer Address City Name	198-227	30	A/N	The insurer’s city where the state sends the insurance intercept request. This field is required.
Insurer Address State Code	228-229	2	A/N	The state alphabetic code where the state sends the insurance intercept request. This field is required.
Insurer Address Zip Code	230-244	15	A/N	The insurer’s ZIP Code. U.S. ZIP Codes must be 5 or 9 characters. Foreign ZIP Codes may be up to 15 characters.
Insurer Address Foreign Country Indicator	245	1	A/N	If the insurer’s address is in a foreign country, enter a numeric ‘1.’
Insurer Address Foreign Country Name	246-270	25	A/N	If the “Insurer Address Foreign Country Indicator” is a ‘1,’ enter the name of the foreign country.
Insurer Contact Last Name	271-300	30	A/N	Your contact’s last name.
Insurer Contact First Name	301-320	20	A/N	Your contact’s first name.
Insurer Contact Phone Number	321-330	10	A/N	Your contact’s phone number.
Insurer Contact Phone Extension Number	331-336	6	A/N	Your contact’s phone number extension.
Insurer Contact Fax Number	337-346	10	A/N	Your contact’s fax number.
Insurer Contact Email	347-386	40	A/N	Your contact’s e-mail address.
Insurer Claim Number	387-416	30	A/N	The unique claim number you assigned.
Insurance Product Claim Type	417-418	2	A/N	The type of claim in this record. Valid values are: 00 – Life 01 – Automobile 02 – Automobile – No fault 03 – Automobile – Medical 04 – Property liability 05 – Workers’ compensation 06 – Personal injury 07 – General liability 08 – Homeowners liability 09 – Medical premise/owner’s policy 10 – Product liability 11 – Slip, trip, and fall 12 – Property damage 13 – Unknown 14 – Disability 15 – Annuity 16 – Policy surrender 17 – Mutual fund 18 – Unemployment 19 – Dividend withdrawals 99 – Other
Insurance Claim State Code	419-420	2	A/N	The state alphabetic code where the insurance loss occurred.
Insurance Claim Loss Date	421-428	8	A/N	The insurance claim or injury date. The date is in the CCYYMMDD format.
Insurance Claim Beneficiary Indicator	429	1	A/N	Specify whether a beneficiary is associated with this life insurance claim. Valid values are: Y – Yes. A beneficiary is associated with this life insurance claim. N – No. A beneficiary is not associated with this life insurance claim.
Insurance Claim Reported Date	430-437	8	A/N	The date the claimant reported the claim to you. The date is in the CCYYMMDD format.
Insurance Claim Status Code	438	1	A/N	The status of the claim. Valid values are: 0 – Open 1 – Closed
Insurance Claim Payout Frequency Code	439	1	A/N	Indicate the frequency of the payouts. Valid values are: 1 – One-time 2 – Weekly 3 – Biweekly 4 – Monthly 5 – Quarterly 6 – Annually 7 – Other
Obligor Match Code	440-441	2	A/N	Claim submitters fill this field with spaces. Matching partners enter the result of the match performed by comparing the obligor identifying information we provided against your data. Valid values are: 00 – Name and Address 01 – Name and DOB 02 – Name and SSN 03 – SSN 04 – SSN and Address 05 – SSN and DOB 06 – SSN, Name, and Address 07 – SSN, Name, and DOB 08 – SSN, Address, and DOB 09 – SSN, Name, Address, and DOB 10 – Name, Address, and DOB
Claimant Last Name	442-471	30	A/N	The claimant’s last name you have on file. This is a required field.
Claimant First Name	472-491	20	A/N	The claimant’s first name you have on file. This is a required field.
Claimant Middle Name	492-507	16	A/N	The claimant’s middle name you have on file.
Claimant ITIN Number	508-516	9	A/N	The claimant’s Individual Taxpayer Identification Number (ITIN) when there is no SSN.
Claimant Birth Date	517-524	8	A/N	The claimant’s date of birth you have on file. The date is in the CCYYMMDD format. If the “Insurer Provided SSN” is not included, then this field or the Claimant Address fields are required.
Claimant Gender Code	525	1	A/N	The claimant’s gender you have on file. Valid values are: F – Female M – Male
Claimant Home Phone Number	526-535	10	A/N	The claimant’s home phone number.
Claimant Business Phone Number	536-545	10	A/N	The claimant’s business phone number.
Claimant Business Phone Extension Number	546-551	6	A/N	The claimant’s business phone number extension.
Claimant Cell Phone Number	552-561	10	A/N	The claimant’s cell phone number.
Claimant Driver License Number	562-581	20	A/N	The claimant’s driver’s license number.
Claimant Driver License State Code	582-583	2	A/N	The state alphabetic code that issued the insurance claimant’s driver’s license.
Claimant Occupation	584-623	40	A/N	The claimant’s occupation.
Claimant Professional License Number	624-638	15	A/N	The claimant’s professional license number.
Claimant Address Line 1	639-678	40	A/N	The claimant’s street address. If the insurer-provided SSN is not included, then the claimant’s address fields or the “Claimant Birth Date” is required.
Claimant Address Line 2	679-718	40	A/N	The claimant’s address information.
Claimant Address City Name	719-748	30	A/N	The claimant’s city.
Claimant Address State Code	749-750	2	A/N	The state alphabetic code for the claimant’s address.
Claimant Address Zip Code	751-765	15	A/N	The ZIP Code for the claimant’s address. U.S. ZIP Codes must be 5 or 9 characters. Foreign ZIP Codes may be up to 15 characters.
Claimant Address Foreign Country Indicator	766	1	A/N	If the claimant’s address is in a foreign country, enter a numeric ‘1.’
Claimant Address Foreign Country Name	767-791	25	A/N	If the “Claimant Address Foreign Country Indicator” is a ‘1,’ enter the name of the foreign country.
Attorney Last Name	792-821	30	A/N	The last name of the claimant’s attorney or firm name.
Attorney First Name	822-841	20	A/N	The first name of the claimant’s attorney.
Attorney Phone Number	842-851	10	A/N	The phone number of the claimant’s attorney.
Attorney Phone Extension Number	852-857	6	A/N	The phone number extension of the claimant’s attorney.
Attorney Address Line 1	858-897	40	A/N	The street address of the claimant’s attorney.
Attorney Address Line 2	898-937	40	A/N	The address information of the claimant’s attorney.
Attorney Address City Name	938-967	30	A/N	The city of the claimant’s attorney.
Attorney Address State Code	968-969	2	A/N	The state alphabetic code of the claimant’s attorney.
Attorney Address Zip Code	970-984	15	A/N	The ZIP Code of the claimant’s attorney. U.S. ZIP Codes must be 5 or 9 characters. Foreign ZIP Codes may be up to 15 characters.
Attorney Address Foreign Country Indicator	985	1	A/N	If the attorney’s address is in a foreign country, enter a numeric ‘1.’
Attorney Address Foreign Country Name	986-1010	25	A/N	If the “Attorney Address Foreign Country Indicator” is a “1,” enter the name of the foreign country.
Third Party Administrator Company Name	1011-1050	40	A/N	The name of the TPA’s company.
Third Party Administrator Contact Last Name	1051-1080	30	A/N	The TPA contact’s last name.
Third Party Administrator Contact First Name	1081-1100	20	A/N	The TPA contact’s first name.
Third Party Administrator Company Phone Number	1101-1110	10	A/N	The TPA contact’s phone number.
Third Party Administrator Company Phone Extension Number	1111-1116	6	A/N	The TPA contact’s phone extension number.
Third Party Administrator Address Line 1	1117-1156	40	A/N	The TPA’s street address.
Third Party Administrator Address Line 2	1157-1196	40	A/N	The TPA’s address information.
Third Party Administrator Address City Name	1197-1226	30	A/N	The TPA’s city.
Third Party Administrator Address State Code	1227-1228	2	A/N	The state alphabetic code for the TPA.
Third Party Administrator Zip Code	1229-1243	15	A/N	The ZIP Code for the TPA’s address. U.S. ZIP Codes must be 5 or 9 characters. Foreign ZIP Codes may be up to 15 characters.
Third Party Administrator Address Foreign Country Indicator	1244	1	A/N	If the TPA’s address is in a foreign country, enter a numeric ‘1.’
Third Party Administrator Address Foreign Country Name	1245-1269	25	A/N	If the “Third Party Administrator Address Foreign Country Indicator” is a ‘1,’ enter the name of the foreign country.
Employer Name	1270-1309	40	A/N	The claimant’s employer.
Employer Phone Number	1310-1319	10	A/N	The employer’s phone number.
Employer Phone Extension Number	1320-1325	6	A/N	The phone extension number for the claimant’s employer.
Employer Address Line 1	1326-1365	40	A/N	The employer’s street address.
Employer Address Line 2	1366-1405	40	A/N	The employer’s address information.
Employer Address City Name	1406-1435	30	A/N	The employer’s city.
Employer Address State Code	1436-1437	2	A/N	The state alphabetic code for the employer.
Employer Address Zip Code	1438-1452	15	A/N	The ZIP Code for the employer’s address. U.S. ZIP Codes must be 5 or 9 characters. Foreign ZIP Codes may be up to 15 characters.
Employer Address Foreign Country Indicator	1453	1	A/N	Enter a numeric ‘1’ if the Employer’s address is in a foreign country.
Employer Address Foreign Country Name	1454-1478	25	A/N	Enter the name of the foreign country if the “Employer Address Foreign Country Indicator” is a ‘1.’
Filler	1479-1487	9	A/N	Reserved for future use, fill with spaces.
Claim Adjuster Name	1488-1517	30	A/N	The name of the insurer’s claim adjuster.
Claim Adjuster Phone	1518-1527	10	A/N	The claim adjuster’s phone number.
NAIC Code	1528-1532	5	A/N	The insurer’s National Association of Insurance Commissioners code.
Filler	1533-1600	68	A/N	Reserved for future use, fill with spaces.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Public reporting burden for this collection of information is estimated to average 5 minutes per electronic response and 6 minutes per manualy response for processing input and output files, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Part A: OCSE Insurance Match Standard Input File Record 6