Send original and one copy of this form and all 

other documentation to: 

Health Education Assistance Loan (HEAL) Program

Program Support Center (PSC)

12501 Ardennes Ave., Suite 100

Rockville, MD 20857

U.S. DEPARTMENT OF EDUCATION

Federal Student Aid

FEDERAL HEALTH EDUCATION ASSISTANCE LOAN (HEAL) PROGRAM

(42 U.S.C. 292-2920) and the Consolidation Appropriations Act, 2014

LENDER’S APPLICATION FOR INSURANCE CLAIM

PRA Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control 

number for this information collection is 1845-0127. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data 

sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefit (Title VII, Part A, Subpart I of the 

Public Health Service Act (42 U.S.C. 294m) and the Consolidated Appropriations Act, 2014). If you have comment or concerns regarding the status of your individual submission of this form, please contact the HEAL Program, 

U.S. Department of Education 830 First Street NE, Washington, DC 20202 directly. [Note: Please do not return the completed form to this address.]

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