Form 1 Insurance Match Debt Inquiry Agreement and Profile

OMB Control No: 0970-0370
Expiration Date: xx/xx/xxxx

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

Insurance Match Debt Inquiry Agreement and Profile

Description of Service
After completing the registration process and receiving your activation code, you can access the
Portal to:
1. Report lump sum or claim payments for claimants who may owe past-due child support.
2. Register as a third-party insurer if you report claim information for more than one insurance
company and use multiple FEINs.

Instructions
Fill out all the required fields in this form and email it to the Portal Help Desk. One of our team
members may contact you if additional information is necessary to complete the registration
process.

Disclaimer
By completing and supplying the information in this form, you agree to:
1. Not impersonate any individual, entity, or association; conceal; or supply misleading
information about my identity while transmitting files.
2. Supply true, accurate, current, and complete information about the entity identified in this
form.
3. Not use any information obtained as a result of involvement with Insurance Match Debt
Inquiry for employment decisions.

Security
The insurer shall have appropriate procedures in place to promptly report confirmed or suspected
information security or privacy incidents, including, but not limited to, unauthorized use or disclosure
of Personally Identifiable Information (PII) involving confidential child support information submitted
through OCSE to your organization. As soon as reasonably practicable after discovery, but in no case
later than one hour after discovery of the incident, the insurer shall report confirmed or suspected
incidents to OCSE as specified in this paragraph. The requirement for the insurer to report confirmed
or suspected incidents involving PII to OCSE is based on federal guidance/requirements from the
Office of Management and Budget (OMB), Health and Human Services (HHS), the Federal
Information Systems Security Modernization (FISMA) Act of 2014, and the United States Computer
Emergency Readiness Team (US-CERT).

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Incidents must be reported via email to OCSE using the security mailbox address:
[email protected]
By selecting Accept, you certify that you have read, understood, and agree to the terms of this
agreement.

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Insurance Match Debt Inquiry Profile
Required *

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

FEIN: *
(Primary Federal Employer Identification Number Format: 123456789)

Organization Type: *
(Select Third Party if reporting claims for multiple FEINs.)

Organization Name: *

Organization Short Name:
(Enter abbreviation for your organization. Maximum 25 characters.)

Address Information
Is this the address where child support agencies should send liens/levies?

Yes

No

Address Line 1: *

Address Line 2:

Address Line 3:

City: *

State: *

ZIP Code (5 digits): *

ZIP Code Ext:

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Required *

Contact Information
Enter business, technical, and Insurance Match Debt Inquiry contact information.

Business Contact Information
Contact Name: *

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

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

Contact Email: *
(Format: [email protected])

Select if you want email notifications sent to this address.

Technical Contact Information
A network or system administrator who can help provide corporate Internet Protocol (IP) address information or batch
system information, if applicable.
Contact Name:

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

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

Contact Email:
(Format: [email protected])

Select if you want email notifications sent to this address.

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Insurance Match Debt Inquiry Contact Information
Enter information for the person in your organization child support agencies should contact if they have questions
about the matches.
Contact Name: *

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

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

Contact Email: *
(Format: [email protected])

Select if you want email notifications sent to this address.

Communication Preference
You must select a preferred method of communication for your organization: email, 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, with no special characters, such as parentheses,
or spaces. 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.xlsx)
We will only process files if your organization has a profile and one registered user in the system.

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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 email the key to you. OCSE will need your organization’s GPG or PGP public key if files
destined for your organization requireencryption.
Encrypt file? *

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

Method of transmission: *

IP Address Information
The federal Office of Child Support Enforcement (OCSE) requires a public Internet Protocol (IP) address from external
partners to allow secure access to the Child Support Portal. OCSE independently verifies the IP address and organization
name with the American Registry for Internet Numbers (ARIN), a regional internet registry for the United States. For more
information, visit the ARIN website.
Enter the public IP addresses your organization uses to access the internet. In most cases, the IP address is your company's
internet proxy server or the public IP address of the computer used to access OCSE's Child Support Portal. To locate your
public IP address, search on the internet for "What Is My Public IP Address." You must verify the addresses with your
network administrator.
Public IP Addresses: *

By completing this section, you certify your organization holds exclusive use of the static IP addresses assigned by an
Internet Service Provider vendor. If the static IP address assigned to your organization changes, you must contact the
Portal Help Desk.
Name of Internet Service Provider: *

(Example: Comcast, AT&T, or Verizon. Enter your
company name if you own your IP address and it
is verifiable on ARIN website.)

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104 -13) STATEMENT OF PUBLIC BURDEN: The purpose of this voluntary information collection is for OCSE to register and
authenticate authorized users of the Insurance Match program. Public reporting estimated burden for this collection of inform ation is 0.08 hours per respondent, including the
time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. As p rovided by 42 U.S.C. § 653(m)(2), any confidential
information collected for this program is accessed only by authorized users. A f ederal agency may not conduct or sponsor an information collection without a valid OMB Control
Number. No individual or entity is required to respond to, nor shall an individual or entity be subject to a penalty for fail ure to comply with a collection of information subject to
the requirements of the Paperwork Reduction Act of 1995, without a current valid OMB Control Number. If you have any comments on this collection of information, please
contact [email protected].

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