Fourth Interim Distribution



Claimant Name
Claimant Address

Liquidator's Proof of Claim No.:

This Fourth Interim Distribution Refunding Agreement (the “Agreement”) is entered into between you, the above-described claimant (“Claimant”), and the New Jersey Insolvent Health Maintenance Organization Assistance Association (the “Association”).

The New Jersey Insolvent Health Maintenance Organization Assistance Fund Act of 2000 (the “Act”) was enacted on April 6, 2000 for the purpose of protecting, subject to certain limitations, covered individuals and providers against the failure or inability of HIP Health Plan of New Jersey, Inc. (“HIP”) and American Preferred Provider Plan, Inc. (“APPP”) to perform certain contractual obligations as a result of insolvency.

The Act established the New Jersey Insolvent Health Maintenance Organization Assistance Association (“Association”) as a nonprofit legal entity to manage the funding and payment of certain eligible claims against HIP and APPP. As a condition of receiving payment directly from the Association for eligible claims, providers of health care services of the insolvent carrier agree to forgive one-third of the unpaid contractual obligations due them.

In addition, the Act provides that Claimant's claims may be subject to retrospective verification or audit and that all, or part, of any interim partial payment or distribution may be reclaimed by the Association as a result of the findings.

In consideration of this Fourth Interim Distribution from the Association, the Claimant agrees as follows:


Claimant agrees that in the event it is determined that some or all of this Fourth Interim Distribution must be returned to the Association as a result of the Claimant receiving a distribution from the Association to which it was not entitled, the Claimant shall refund to the Association all or that portion of all applicable interim distributions as requested by the Association within thirty (30) days of receipt of written request thereof.

The final determination with respect to reclaim situations will be based upon:

(i)  further developments as a result of the insolvent carriers continued claim adjudication work and/or,

(ii) negligence, fraud or mistake by the Claimant.

Claimant's failure to remit all or a portion of the recalled interim distributions to the Association within thirty (30) days of receipt of written request shall cause interest to accrue on and after the due date at the percentage of interest prescribed in the rules governing the Court of the State of New Jersey for judgments, awards and orders for the payment of money.


Claimant agrees to assign its rights to payments against the insolvent carrier to the Association with respect to this Fourth Interim Distribution.


If the Association determines in good faith that the Claimant has failed to comply with any provision of this Fourth Interim Distribution Refunding Agreement, the Association retains the right, in addition to any other rights it may have, to setoff against any future disbursements to the Claimant the amount due to the Association and to withhold monies which would otherwise be distributable to the Claimant.

Further, upon finalizing the claim, if it is determined that multiple claims were filed for the same occurrence by related parties, the Association reserves the right to combine all such claims including any interim distributions paid. Future claim payments, if any, as well as any right of recovery matters will be addressed with and through the recognized primary entity.


Any disputes arising in connection with this Agreement shall be resolved in accordance with the laws of the State of New Jersey .


Any notice required or permitted under the terms of this Agreement to be given to the parties shall be deemed given:

(i)  if actually received by the intended recipient by any means of manual delivery or electronic transmission;

(ii)  if posted by prepaid certified mail, return receipt requested; or

(iii)  if consigned to and receipted by a commercial delivery service and addressed as follows:

If to the Association:

NJ Insolvent Health Maintenance Organization Assistance Association
c/o New Jersey Department of Banking & Insurance
Office of Financial Solvency, 8th Floor
20 West State Street
PO Box 325
Trenton, New Jersey 08625-0325

With Copy To:

Deputy Liquidator
Deputy Liquidator's Address

If to Claimant:

Claimant Name
Claimant Address
Telephone No.: __________________________________
Facsimile No.: ___________________________________


This Agreement supersedes all prior offers and agreements of every kind and expresses the full intent of the parties. This Agreement shall not be modified except by an instrument in writing, executed by the authorized representatives of each of the parties. No oral modifications apply.  


This Agreement shall be binding upon and shall inure to the benefit of the parties hereto and their respective successors and assigns including, but not limited to, a trustee in bankruptcy.


The negotiation, execution, terms, delivery and/or performance of this Agreement shall not be construed as an admission by the Association of any liability to the Claimant except as set forth herein, and shall not be admissible in any trial or pretrial proceedings between the parties, except to enforce this Agreement.


Claimant's endorsement, deposit or negotiation of the enclosed Fourth Interim Distribution check in any manner whatsoever constitutes Claimant's acceptance of all terms and conditions of this Agreement without exception.