Form 1 Debt Inquiry Services Insurer Agreement and Profile Form

DIS Insurer Agreement and Profile
OMB Contol No.: 0970-0370

CSP Registration
Expires: xx/xx/xxxx

Department of Health and Human Services
Administration for Families and Children
Office of Child Support Enforcement

Debt Inquiry Service (DIS) Insurer Agreement and Profile
By completing and providing the information contained in the "Debt Inquiry Insurer
Profile Form," the insurance company or the agent of an insurance company agrees that it will:
·

Provide information about individuals who are eligible to receive an insurance claim,
payment, settlement, and/or award.

·

Only use the information resulting from the data match for the purpose of contacting
state child support agencies. In accordance with Section 452 of the Social Security Act,
the information provided to insurers (or their designated agents) for purposes of
conducting the data matches may not be used by such insurers or agents for any other
purposes and may not be re-disclosed to any person except to the extent necessary to
conduct the data matches. There may also be additional prohibitions or penalties which
apply under state law.

·

Not impersonate any individual, entity, or association, use false headers, or otherwise
conceal or provide misleading information about it's identity while providing information
to and receiving information from the DIS.

·

Provide true, accurate, current, and complete information about the entity identified
in the profile form.

·

Provide written notice to the Federal Office of Child Support Enforcement, at least 30
days in advance, of its intent to no longer provide Debt Inquiry Payout files.

·

Not use any information obtained as a result of involvement with the Debt Inquiry
Service for employment decisions.

The Deficit Reduction Act of 2005, Pub. L. 109-171, s. 7306, amended Section 452 of the Social
Security Act and authorizes OCSE, through the Federal Parent Locator Service, to “compare
information concerning individuals owing past-due child support with information maintained
by insurers (or their agents) concerning claims, settlements, awards, and payments.” 42 U.S.C.
652(l) (to be redesignated 42 U.S.C. 652(m)). The legislation includes a non-liability clause
regarding insurer disclosure or any other action taken in accordance with this subsection.
An insurer's election to participate in the OCSE Debt Inquiry Service data match shall not be
construed as consent to participate in any other centralized data process. When completed by a
representative of the insurer (or their agent), this profile form will serve as the official operational
agreement between the organization and OCSE.
By checking "Accept" you certify that you have read, understood and agree to the terms of this
agreement.
Accept

Decline

Page 1 of 6

DIS Insurer Agreement and Profile
OMB Contol No.: 0970-0370

CSP Registration
Expires: xx/xx/xxxx

Debt Inquiry Profile Form

Debt Inquiry
Required *

General Information
Enter general information about your organization and participation in the Debt Inquiry Service.
Start Date: *
(MM/DD/YYYY)

FEIN: *
(Primary Federal Employer Identification Number, the FEIN that your organization will use on the batch
for files being transferred. Format: 123456789)

Organization Type: *

Organization Name: *

Organization Short Name:
(Supply a shortened name, abbreviation, or acronym
for your organization.)

Address Information
Address Line 1: *

Address Line 2:

Address Line 3:

City: *

State: *

Zip Code:

*
Format: 12345 or 123456789

Page 2 of 6

DIS Insurer Agreement and Profile
OMB Contol No.: 0970-0370

CSP Registration
Expires: xx/xx/xxxx

Contact Information
Enter business, debt inquiry, and technical contact information.

Business Contact Information
Enter business contact information.
Contact Name: *

Contact Phone Number: *
(Enter numeric digits only, including area code. Format: 1231231111)

Contact Fax:
(Enter numeric digits only, including area code. Format 1231231111)

Contact E-mail: *
(Format: [email protected])

✔

Click if you want E-mail notifications sent to this E-mail address

Debt Inquiry Contact Information
Enter debt inquiry contact information.
Contact Name: *

Contact Phone Number: *
(Enter numeric digits only, including area code. Format: 1231231111)

Contact Fax:
(Enter numeric digits only, including area code. Format: 1231231111)

Contact E-mail: *
(Format: [email protected])

✔

Click if you want E-mail notifications sent to this E-mail address

Page 3 of 6

DIS Insurer Agreement and Profile
OMB Contol No.: 0970-0370

CSP Registration
Expires: xx/xx/xxxx

Technical Support Contact Information
Enter technical support contact information.
Contact Name: *

Contact Phone Number: *
(Enter numeric digits only, including area code. Format: 1231231111)

Contact Fax:
(Enter numeric digits only, including area code. Format: 1231231111)

Contact E-mail: *
(Format: [email protected])

Click if you want E-mail notifications sent to this E-mail address

Communication Preference
You must select a preferred method of communication for your organization: E-mail, fax, or phone.

Communication Preference: *

File Information
Your organization must submit Debt Inquiry Payout files as .csv, .txt, .xls, and .xlsx files only. File names must start with 'FEIN.
DI.'. The file names must only contain alphanumeric characters, no characters such as spaces or parentheses. If your
organization submits multiple files on one day, each file name must be unique. A suggested approach is to append a date
and a sequence number to the file name. (Example: 123456789.DI.06092012.33.xls)
We will only process files if your organization has a profile and registered user in the system.
I

Page 4 of 6

File Encryption:
If you choose file encryption, your organization must use OCSE's GPG public key to encrypt files destined for OCSE. The OCSE
portal network administrator will e-mail the key to you. OCSE will need your organization's GPG (or) PGP public key if files
destined for your organization require encryption.
Encrypt File? *
Yes

No

Transmission Method:
Choose how Debt Inquiry Payout files will be transferred to OCSE.

Method of Transmission: *
Debt Inquiry web application
Partner will send to OCSE
OCSE will retrieve from partner

Page 5 of 6

Server Information
If you select “Debt Inquiry web application” as the transmission method, provide the public source IP addresses used by your
organization to access the internet. In most cases, the addresses will be those of your company's internet proxy
servers. Verify addresses with your network administrator.

IP Address Information
Public Source IP Address:
Public Source IP Address:
Public Source IP Address:
If you select “Partner will send to OCSE” as the transmission method, only fill in the IP address and port or host name and port
for your production server and test server (if applicable). The OCSE portal network administrator will e-mail OCSE connection
information to your organization's technical contact.
If you select “OCSE will retrieve from Partner” as the transmission method, fill in either an IP address or a host name entered
for your production and test servers (if applicable). Both are not required.

Production Server
User ID:
Password:
IP Address:
Host Name:
Port:
Directory Name:

Page 6 of 6

Server Information
Test Server
User ID:
Password:
IP Address:
Host Name:
Port:
Directory Name:

Public reporting burden for this collection of information is estimated to average 0.08 hours, 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.

Page 7 of 6