Welcome to the Child Support Lien Network
Connecticut
Connecticut Confidentiality Statement
The undersigned insurance company, _________________________ (Enter company name), including and on behalf of its employees, directors, subcontractors and agents, hereby agrees to review, and otherwise protect from unauthorized use or disclosure, all personal and financial information obtained from the CSLN web site and to use this data only for the purpose and to the extent necessary to match insurance claimants to delinquent child support obligors in order to facilitate the child support program's collection efforts.
The undersigned explicitly acknowledges a duty not to disclose information gathered from any source that reveals to the claimant the whereabouts of the claimant's child or spouse, ex-spouse or parent of claimant's child.
The undersigned agrees to comply with the appropriate laws of all states in which the undersigned does business and whose laws may apply in a specific child support insurance intercept case. These laws may include specific lien, levy or offset requirements of the insurer and specific rights or immunities of liability for the taking of such actions that may benefit or be claimed by the undersigned. By signing below, the undersigned acknowledges that any postings of such specific state laws, rights and immunities found on this CSLN web site is intended to be for informational assistance to the insurer only and may not necessarily be representative of the entire statute, provision or amendment that may be found under the appropriate publication source of a state's general laws and provisions on these subjects.
The undersigned acknowledges that this CSLN method of matching insurance claimants to delinquent child support obligors for asset collection purposes is an alternative method to a case-by-case or blanket subpoenaing of asset information that is possible under the administrative enforcement provisions of child support laws enacted in every state. The undersigned understands that all CSLN members will attempt to use CSLN procedures and any relevant seizure, levy or execution laws in lieu of a case-by-case method of insurance settlement interception.
I UNDERSTAND THAT TYPING THE DATE, MY NAME AND TITLE AND CLICKING THE "E-MAIL THE FORM" BUTTON ON THIS FORM BINDS ME, MY COMPANY, ITS EMPLOYEES, DIRECTORS, SUBCONTRACTORS AND AGENTS TO THE SAME EXTENT AS A WRITTEN SIGNATURE.
Name |
_______________________ |
Date |
_______________________ |
Title |
_______________________ |
|
|
Company ______________________________ |
|||
The Confidentiality Statement must be submitted before access to the secure Insurance Intercept site is approved. A signed original confidentiality form must be mailed to:
Connecticut Intercept Program
600 Longwater Drive, Suite 202
Norwell, MA 02061
To Print the form, print from your browser, sign it and fax it to (781) 623-8030.