Form 1 File input

OMB Control Number: 0970-0342

Expiration Date: xx/xx/20xx

OCSE INSURANCE MATCH STANDARD INPUT FILE DETAIL RECORD
Field Name	Location	Length	A/N	Comments
Record Identifier	1-2	2	A/N	This field contains the character “ID”.
Insurer Processing Date	3-10	8	A/N	This field contains the date the Insurer record was created or updated by the Insurer within its system. The date is in the CCYYMMDD format.
Insurer Provided SSN	11-19	9	A/N	This field contains the SSN for the claimant.
Obligor SSN	20-28	9	A/N	This field contains the Obligor SSN that was provided by OCSE to the Insurance Matching agency for its use in identifying a claimant.
Obligor Last Name	29 – 48	20	A/N	This field contains the person’s last name for the SSN that was provided by OCSE to the Insurance Matching agency for its use in identifying a claimant.
Obligor First Name	49-63	15	A/N	This field contains the person’s first name for the SSN that was provided by OCSE to the Insurance Matching agency for its use in identifying the Claimant.
Insurer Identifier	64-72	9	A/N	This field contains either: a valid nine-digit Taxpayer Identification Number assigned to the Insurer, a Federal Employee Identification Number (FEIN), or another designated identification.
Insurer Name	73-117	45	A/N	This field contains the name of the Insurer where the insurance claim is maintained and to which the State is directed to send the insurance intercept request for processing. If not provided, this field contains all spaces.
Insurer Address Line 1	118-157	40	A/N	This field contains Insurer address information within this first street field. If not provided, this field contains all spaces.
Insurer Address Line 2	158-197	40	A/N	This field contains Insurer address information within this second street field. If not provided, this field contains all spaces.
Insurer Address City Name	198-227	30	A/N	This field contains the city that is associated with the Insurer address.
Insurer Address State Code	228-229	2	A/N	This field contains the alphabetic code for the State that is associated with the Insurer address.
Insurer Address Zip Code	230-244	15	A/N	This field contains the Zip Code that is associated with the Insurer address. U.S. Zip Codes are 5-4 digits, and foreign Zip Codes may be up to 15 characters.
Insurer Address Foreign Country Indicator	245	1	A/N	This field contains one of the following values to indicate if the Insurer address provided is a US or foreign address: 1 – The address of the Insurer is in a foreign country Space – The address of the Insurer is in the US
Insurer Address Foreign Country Name	246-270	25	A/N	If the returned address is in a foreign country, this field contains the name of the foreign country. If the address is not in a foreign country, this field contains all spaces.
Insurer Contact Last Name	271-300	30	A/N	This field contains the last name of the Insurer contact. If not provided, this field contains all spaces.
Insurer Contact First Name	301-320	20	A/N	This field contains the first name of the Insurer contact. If not provided, this field contains all spaces.
Insurer Contact Phone Number	321-330	10	A/N	This field contains the phone number of the Insurer contact. If not provided, this field contains all spaces.
Insurer Contact Phone Extension Number	331-336	6	A/N	This field contains the phone number extension of the Insurer contact. If not provided, this field contains all spaces.
Insurer Contact Fax Number	337-346	10	A/N	This field contains the fax number of the Insurer contact. If not provided, this field contains all spaces.
Insurer Contact Email	347-386	40	A/N	This field contains the email address of the Insurer contact. If not provided, this field contains all spaces.
Insurer Claim Number	387-416	30	A/N	This field contains the claim number assigned by the Insurer.
Insurance Product Claim Type	417-418	2	A/N	This field contains the code indicating the type of claim matched by the Insurance Matcher. The 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/Owners Policy 10 – Product Liability 11 – Slip, Trip and Fall 12 – Other
Insurance Claim State Code	419-420	2	A/N	This field contains the alphabetic FIPS code for the State in which the insurance loss occurred. If not provided, this field contains all spaces.
Insurance Claim Loss Date	421-428	8	A/N	This field contains the date of the insurance claim loss by the Claimant. The date is in the CCYYMMDD format. If not provided, this field contains all spaces.
Insurance Claim Beneficiary Indicator	429	1	A/N	This field contains an indicator specifying whether a beneficiary is associated with this life insurance claim. Y – Yes. A beneficiary is associated with this life insurance claim. N – No. A beneficiary is not associated with this life insurance claim. If not provided, this field contains all spaces.
Insurance Claim Reported Date	430-437	8	A/N	This field contains the date the claim was reported by the Claimant to the Insurer. The date is in the CCYYMMDD format. If not provided, this field contains all spaces.
Insurance Claim Status Code	438	1	A/N	This field contains one of the following codes to indicate the status of the claim: 0 – Matched claim open at the time of the match by the Insurer. 1 – Matched claim closed at the time of the match by the Insurer. If not provided, this field contains all spaces.
Insurance Claim Payout Frequency Code	439	1	A/N	This field contains a code associated with the frequency of the Insurer claim payout. 1 – One-Time 2 – Weekly 3 – Bi-Weekly 4 – Monthly 5 – Quarterly 6 – Annually 7 – Other
Obligor Match Code	440-441	2	A/N	This field indicates the result of the match performed by the Insurance Matcher that compares the provided obligor’s identifying information against insurance claim data. The 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	This field contains the last name of the Claimant from the insurance data match.
Claimant First Name	472-491	20	A/N	This field contains the first name of the Claimant from the insurance data match.
Claimant Middle Name	492-507	16	A/N	This field contains the middle name of the Claimant from the insurance data match. If not provided, this field contains all spaces.
Claimant ITIN Number	508-516	9	A/N	This field contains the Individual Taxpayer Identification Number for the Claimant. If not provided, this field contains all spaces.
Claimant Birth Date	517-524	8	A/N	This field contains, if available, the date of birth of the Claimant from the Insurer data match. The date is in the CCYYMMDD format. If not provided, this field contains spaces.
Claimant Gender Code	525	1	A/N	This field contains the code that indicates the gender of the Claimant as stored in the Insurer data base. F – Female M – Male If not available, this field contains a space.
Claimant Home Phone Number	526-535	10	A/N	This field contains the home phone number of the Claimant. If not provided, this field contains all spaces.
Claimant Business Phone Number	536-545	10	A/N	This field contains the business phone number of the Claimant. If not provided, this field contains all spaces.
Claimant Business Phone Extension Number	546-551	6	A/N	This field contains the business phone number extension of the Claimant. If not provided, this field contains all spaces.
Claimant Cell Phone Number	552-561	10	A/N	This field contains the cell phone number of the Claimant. If not provided, this field contains all spaces.
Claimant Driver License Number	562-581	20	A/N	This field contains the driver license number of the Claimant. If not provided, this field contains all spaces.
Claimant Driver License State Code	582-583	2	A/N	This field contains the driver’s license alphabetic code for the State of the Claimant. If not provided, this field contains all spaces.
Claimant Occupation	584-623	40	A/N	This field contains the occupation of the Claimant. If not provided, this field contains all spaces.
Claimant Professional License Number	624-638	15	A/N	This field contains the professional license number of the Claimant. If not provided, this field contains all spaces.
Claimant Address Line 1	639-678	40	A/N	This field contains Claimant address information within this first street field. If not provided, this field contains all spaces.
Claimant Address Line 2	679-718	40	A/N	This field contains Claimant address information within this second street field. If not provided, this field contains all spaces.
Claimant Address City Name	719-748	30	A/N	This field contains the city that is associated with the Claimant address. If not provided, this field contains all spaces.
Claimant Address State Code	749-750	2	A/N	This field contains the alphabetic code for the State that is associated with the Claimant address. If not provided, this field contains all spaces.
Claimant Address Zip Code	751-765	15	A/N	This field contains the Zip Code that is associated with the Claimant address. U.S. Zip Codes are 5-4 digits, and foreign Zip Codes may be up to 15 characters. If not provided, this field contains all spaces.
Claimant Address Foreign Country Indicator	766	1	A/N	This field contains one of the following values to indicate if the Claimant address provided is US or foreign address: 1 – The address of the Claimant is in a foreign country Space – The address of the Claimant is in the US
Claimant Address Foreign Country Name	767-791	25	A/N	If the returned address is in a foreign country, this field contains the name of the foreign country associated with the Claimant address. If the country name is not provided, this field contains all spaces. If the address is not in a foreign country, this field contains all spaces.
Attorney Last Name	792-821	30	A/N	This field contains the last name of the Attorney for this claim. If not provided, this field contains all spaces.
Attorney First Name	822-841	20	A/N	This field contains the first name of the Attorney for this claim. If not provided, this field contains all spaces.
Attorney Phone Number	842-851	10	A/N	This field contains the phone number of the Attorney. If not provided, this field contains all spaces.
Attorney Phone Extension Number	852-857	6	A/N	This field contains the phone number extension of the Attorney. If not provided, this field contains all spaces.
Attorney Address Line 1	858-897	40	A/N	This field contains Attorney address information within this first street field. If not provided, this field contains all spaces.
Attorney Address Line 2	898-937	40	A/N	This field contains Attorney address information within this second street field. If not provided, this field contains all spaces.
Attorney Address City Name	938-967	30	A/N	This field contains the city that is associated with the Attorney address. If not provided, this field contains all spaces.
Attorney Address State Code	968-969	2	A/N	This field contains the alphabetic code for the State that is associated with the Attorney address. If not provided, this field contains all spaces.
Attorney Address Zip Code	970-984	15	A/N	This field contains the Zip Code that is associated with the address. U.S. Zip Codes are 5-4 digits, and foreign Zip Codes may be up to 15 characters. If not provided, this field contains all spaces.
Attorney Address Foreign Country Indicator	985	1	A/N	This field contains one of the following values to indicate if the Attorney address provided is US or foreign address: 1 – The address of the Attorney is in a foreign country Space – The address of the Attorney is in the U.S.
Attorney Address Foreign Country Name	986-1010	25	A/N	If the returned address for the Attorney is in a foreign country, this field contains the name of the foreign country. If the address is not in a foreign country, this field contains all spaces.
Third Party Administrator Company Name	1011-1050	40	A/N	This field contains the name of the Third Party Administrator (TPA) company. If not provided, this field contains all spaces.
Third Party Administrator Contact Last Name	1051-1070	30	A/N	This field contains the last name of the TPA contact. If not provided, this field contains all spaces.
Third Party Administrator Contact First Name	1071-1100	20	A/N	This field contains the first name of the TPA contact. If not provided, this field contains all spaces.
Third Party Administrator Company Phone Number	1101-1110	10	A/N	This field contains the phone number of the TPA company contact. If not provided, this field contains all spaces.
Third Party Administrator Company Phone Extension Number	1111-1116	6	A/N	This field contains the phone extension number of the TPA company contact. If not provided, this field contains all spaces.
Third Party Administrator Address Line 1	1117-1156	40	A/N	This field contains TPA company address information within this first street field. If not provided, this field contains all spaces.
Third Party Administrator Address Line 2	1157-1196	40	A/N	This field contains TPA company address information within this second street field. If not provided, this field contains all spaces
Third Party Administrator Address City Name	1197-1226	30	A/N	This field contains the city that is associated with the TPA company address. If not provided, this field contains all spaces.
Third Party Administrator Address State Code	1227-1228	2	A/N	This field contains the alphabetic code for the State that is associated with the TPA company address. If not provided, this field contains all spaces.
Third Party Administrator Zip Code	1229-1243	15	A/N	This field contains the Zip Code that is associated with the TPA address. U.S. Zip Codes are 5-4 digits, and foreign Zip Codes may be up to 15 characters. If not provided, this field contains all spaces.
Third Party Administrator Address Foreign Country Indicator	1244	1	A/N	This field contains one of the following values to indicate if the TPA company address provided is US or foreign address: 1 – The address of the TPA is in a foreign country Space – The address of the TPA is in the U.S.
Third Party Administrator Address Foreign Country Name	1245-1269	25	A/N	If the returned address associated with the TPA company is in a foreign country, this field contains the name of the foreign country. If the address is not in a foreign country, this field contains all spaces.
Employer Name	1270-1309	40	A/N	This field contains the name of the Employer (of the Claimant). If not provided, this field contains all spaces.
Employer Phone Number	1310-1319	10	A/N	This field contains the phone number of the Employer. An additional extension number may be provided as part of this number. If not provided, this field contains all spaces.
Employer Phone Extension Number	1320-1325	6	A/N	This field contains the phone extension number of the Employer. If not provided, this field contains all spaces.
Employer Address Line 1	1326-1365	40	A/N	This field contains the Employer address information within this first street field. If not provided, this field contains all spaces.
Employer Address Line 2	1366-1405	40	A/N	This field contains the Employer address information within this second street field. If not provided, this field contains all spaces.
Employer Address City Name	1406-1435	30	A/N	This field contains the city that is associated with the Employer address. If not provided, this field contains all spaces.
Employer Address State Code	1436-1437	2	A/N	This field contains the alphabetic code for the State that is associated with the Employer address. If not provided, this field contains all spaces.
Employer Address Zip Code	1438-1452	15	A/N	This field contains the Zip Code that is associated with the Employer address. U.S. Zip Codes are 5-4 digits, and foreign Zip Codes may be up to 15 characters. If not provided, this field contains all spaces.
Employer Address Foreign Country Indicator	1453	1	A/N	This field is to contain one of the following values to indicate if the Employer address provided is a US or foreign address: 1 – The address of the Employer is in a foreign country. Space – The address of the Employer is in the U.S.
Employer Address Foreign Country Name	1454-1478	25	A/N	If the returned address associated with the Employer is in a foreign country, this field contains the name of the foreign country. If the address is not in a foreign country, this field contains all spaces.
Filler	1479-1600	122	A/N	Reserved for future use. For this version this field contains spaces.

Public Reporting burden for this collection of information is estimated to average 0.5hour per response, 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

OMB Control Number: 0970-0342 Expiration: xx/xx/20xx

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