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. 292-2920)

LENDER’S APPLICATION FOR INSURANCE CLAIM

Public Burden Statement: According to the Paperwork Reduction Act of 1995, 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. The OMB control number for this project is 0915-0036. Public burden is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

General Information:

The amount of Federal insurance payment received depends upon whether there is compliance with HEAL statue, regulations, and policies, including those

concerned with the making, servicing, and collection of the loan(s) and the

timely submission of documents. (See Section 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 reside (if applicable) and zip code.

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, and signify yes or no answers by placing an “X” in the appropriate

box.

NOTE: Go to Item 5, 6, 7, 8, 9, 10, 11, or 12 according to claim type selected.

Item 5. Judgment Claim Fill in the information requested or check yes or no.

Item 6. Bankruptcy Claim Fill in all information requested or check yes or no.

Item 7. Skip Claim Fill in all information requested or check yes or no.

Item 8. Unable to Serve Claim Fill in all information requested or check yes or no.

Item 9. Disability Claim Fill in all information requested or check yes or no.

Item 10. Death Claim Fill in all information requested or check yes or no.

Item 11. Low Loan Amount Claim Check yes or no.

Item 12. Low Balance Claim Check yes or no.

Item 13. Enter the total amount of principal and interest for all loans claimed.

Items 14a., 14b., and 14c. 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 one copy of this form and all other documentation to:

Health Education Assistance Loan (HEAL) Program

Parklawn Building, Room 9-105

5600 Fishers Lane

Rockville, Maryland 20857