Early Retiree Reinsurance Program - Private Application

Early Retiree Reinsurance Program

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10321 Early Retiree Reinsurance Program - Private Application Form
CMS-10321.Application Instructions.docx Instruction
CMS-10321 ERRP Application CMS-10321.collection instrument.docx Form

Information Collection (IC) Details

IC Title:	Early Retiree Reinsurance Program - Private 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:

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: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	105,000	105,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.