HEAL Lender's Application for Insurance Claim

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

FEDERAL HEALTH EDUCATION ASSISTANCE LOAN (HEAL) PROGRAM

(42 U.S.C. 292-292o)

LENDER’S APPLICATION FOR INSURANCE CLAIM

PUBLIC BURDEN STATEMENT: An agency may not conduct or sponsor and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0915-0036. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, MD. 20857.

General Information

The amount of Federal insurance payment received depends upon whether there is compliance with HEAL statute, regulations, and policies, including those concerned with the making, servicing, and collection of the loan or loans, and the timely submission of documents. (See Sections 60.13 and 60.38 through 60.41.)

The following documents will assist you in completing this form: (1) HEAL Statute and Regulations; (2) Copy of borrower’s application(s); (3) Original Promissory Note(s); (4) Copy of disbursement check(s); (5) Copy of borrower’s deferment request(s); (6) Evidence of student enrollment status and date of separation; (7) Repayment schedule(s); (8) Copy of borrower’s forbearance request(s); (9) Litigation, bankruptcy, death, or disability documents; and

(10) Payment and servicing history of borrower’s account.

Instructions for completing the form

Item 1a. Holder (owner) of the HEAL loans. Provide six-digit holder identification number, institution’s name, address, city, state, zip code, telephone number, including area code, and fax number.

Item 1b. Servicer may be the same organization as the holder or a different organization. This is where the loans are being serviced. Provide six-digit holder identification number, institution’s name, address, city, state, zip code, telephone number, including area code, and fax number.

Item 1c. Claim Type. Place an “X” in the appropriate box that reflects the type of claim submitted.

Item 2. Provide borrower’s name (if name has changed enter former name in parentheses), social security number, last known address, including city, state, name of foreign country borrower resides (if applicable),and zipcode.

Item 3. Provide 12-digit HEAL Loan ID Number for each loan included in the claim, original loan and disbursed amount. For each loan ID number listed the holder must check appropriate columns as to documents included in the claim package under promissory note, application, repayment schedule, payment history, principal/interest calculation worksheet, and the number of months in deferment and forbearance.

Item 4. Claim Information. Complete all information requested regarding dates, yes or no answers by placing an “X” in the appropriate box.

NOTE: Go to Item 5, 6, 7, 8, 9, 10, or 11 according to claim type selected.

Item 5. Judgment Claim. Fill in all information requested.

Item 6. Bankruptcy Claim. Fill in all information requested.

Item 7. Skip Claim. Fill in all information requested.

Item 8. Unable to Serve Claim. Fill in all information requested.

Item 9. Disability Claim. Fill in all information requested.

Item 10. Death Claim. Fill in all information requested.

Item 11. Low Balance Claim. Fill in all information requested.

Item 12. Enter the total amount of principal and interest for all loans claimed.

Item 12a. Self-explanatory.

The following must be completed before submitting the form:

-- Assigned promissory note(s) to the United States Government.

-- Certified copy of the judgment and original assignment of the judgment to the United States Government.

-- A signed claim form with supporting documentation.

Send original and 2 copies of the claim form and all documentation to:

Health Education Assistance Loan Program

Parklawn Building, Room 8-37

5600 Fishers Lane

Rockville, Maryland 20857