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pdfOMB Control Number: 0970-0342
Expiration Date: XX/XX/20XX
Part A: OCSS Insurance Match Standard Input File Record
A.
OCSS 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
Location
Length
A/N
Comments
Identifies the name of the field.
Identifies the position of the field in the record.
Identifies the size of the field in bytes.
Designates the type of field: alphabetic (A), numeric (N), or alphanumeric (A/N).
Provides a description of the field, as well as valid values.
CHART A-1: OCSS INSURANCE MATCH STANDARD INPUT FILE RECORD
Field Name
Location
Length
A/N
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.
Part A: OCSS Insurance Match Standard Input File Record
Comments
A-1
OMB Control Number: 0970-0342
Expiration Date: XX/XX/20XX
Part A: OCSS Insurance Match Standard Input File Record
CHART A-1: OCSS INSURANCE MATCH STANDARD INPUT FILE RECORD
Field Name
Location
Length
A/N
Comments
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.
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 Address
Foreign Country
Indicator
Part A: OCSS Insurance Match Standard Input File Record
A-2
OMB Control Number: 0970-0342
Expiration Date: XX/XX/20XX
Part A: OCSS Insurance Match Standard Input File Record
CHART A-1: OCSS INSURANCE MATCH STANDARD INPUT FILE RECORD
Field Name
Location
Length
A/N
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
Insurance Claim State
Code
419-420
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
The state alphabetic code where the insurance loss occurred.
Part A: OCSS Insurance Match Standard Input File Record
Comments
A-3
OMB Control Number: 0970-0342
Expiration Date: XX/XX/20XX
Part A: OCSS Insurance Match Standard Input File Record
CHART A-1: OCSS INSURANCE MATCH STANDARD INPUT FILE RECORD
Field Name
Location
Length
A/N
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
430-437
8
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.
The date the claimant reported the claim to you. The date is in
the CCYYMMDD format.
Insurance Claim Status
Code
438
1
A/N
Insurance Claim
Payout Frequency
Code
439
1
A/N
Insurance Claim
Reported Date
Part A: OCSS Insurance Match Standard Input File Record
Comments
The status of the claim. Valid values are:
0 – Open
1 – Closed
Indicate the frequency of the payouts. Valid values are:
1 – One-time
2 – Weekly
3 – Biweekly
4 – Monthly
5 – Quarterly
6 – Annually
7 – Other
A-4
OMB Control Number: 0970-0342
Expiration Date: XX/XX/20XX
Part A: OCSS Insurance Match Standard Input File Record
CHART A-1: OCSS INSURANCE MATCH STANDARD INPUT FILE RECORD
Field Name
Location
Length
A/N
Obligor Match Code
440-441
2
A/N
Claimant Last Name
442-471
30
A/N
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.
Part A: OCSS Insurance Match Standard Input File Record
Comments
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
The claimant’s last name you have on file.
This is a required field.
A-5
OMB Control Number: 0970-0342
Expiration Date: XX/XX/20XX
Part A: OCSS Insurance Match Standard Input File Record
CHART A-1: OCSS INSURANCE MATCH STANDARD INPUT FILE RECORD
Field Name
Location
Length
A/N
Claimant Gender Code
525
1
A/N
Claimant Home Phone
Number
526-535
10
A/N
The claimant’s gender you have on file. Valid values are:
F – Female
M – Male
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.
Part A: OCSS Insurance Match Standard Input File Record
Comments
A-6
OMB Control Number: 0970-0342
Expiration Date: XX/XX/20XX
Part A: OCSS Insurance Match Standard Input File Record
CHART A-1: OCSS INSURANCE MATCH STANDARD INPUT FILE RECORD
Field Name
Location
Length
A/N
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.
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.
Claimant Address
Foreign Country
Indicator
Part A: OCSS Insurance Match Standard Input File Record
Comments
A-7
OMB Control Number: 0970-0342
Expiration Date: XX/XX/20XX
Part A: OCSS Insurance Match Standard Input File Record
CHART A-1: OCSS INSURANCE MATCH STANDARD INPUT FILE RECORD
Field Name
Location
Length
A/N
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.
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.
Attorney Address Zip
Code
Attorney Address
Foreign Country
Indicator
Part A: OCSS Insurance Match Standard Input File Record
Comments
A-8
OMB Control Number: 0970-0342
Expiration Date: XX/XX/20XX
Part A: OCSS Insurance Match Standard Input File Record
CHART A-1: OCSS INSURANCE MATCH STANDARD INPUT FILE RECORD
Field Name
Location
Length
A/N
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.
Part A: OCSS Insurance Match Standard Input File Record
Comments
A-9
OMB Control Number: 0970-0342
Expiration Date: XX/XX/20XX
Part A: OCSS Insurance Match Standard Input File Record
CHART A-1: OCSS INSURANCE MATCH STANDARD INPUT FILE RECORD
Field Name
Location
Length
A/N
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.
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.
Employer Address
Foreign Country
Indicator
Comments
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this voluntary information collection is
to compare information regarding individuals owing past-due child support with information maintained by insurers pertaining to claims, settlements, awards,
and payments to assist state child support agencies collect past-due support. Public reporting estimated burden for this collection of information is 0.083 hours
per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. As
provided by the 42 U.S.C. § 653(m), any confidential information collected for this program is secured and accessed only by authorized users. A federal
agency may not conduct or sponsor, and no individual or entity is required to respond to, nor shall an individual or entity be subject to a penalty for failure to
comply with a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless that collection of information displays a
currently valid OMB Control Number. If you have any comments on this collection of information, please contact [email protected]
Part A: OCSS Insurance Match Standard Input File Record
A-10
| File Type | application/pdf |
| File Modified | 2023-10-17 |
| File Created | 2017-10-18 |