Information Collection

Early Retiree Reinsurance Program - Public Application

IC 192754 under ICR 201004-0938-012 · OMB 0938-1087.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1087 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10321 Early Retiree Reinsurance Program - Public Application	Form
CMS-10321.Application Instructions.docx	Instruction
CMS-10321 ERRP Application CMS-10321.collection instrument.docx	Form

IC Title:

Early Retiree Reinsurance Program - Public Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 149.40

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10321	ERRP Application	CMS-10321.collection instrument.docx		Yes	No	Fillable Fileable
Instruction			CMS-10321.Application Instructions.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	52,500	52,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.