Information Collection

Early Retiree Reinsurance Program - Private Application

IC 192755 under ICR 201005-0938-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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 - Private Application	Form
ERRP Hard Copy Application Instructions Draft 05_26_2010.docx	Instruction
CMS-10321 CMS-10321.ERRP Application ERRP Hard Copy Application Draft 05_26_2010 (2).docx	Form

IC Title:

Early Retiree Reinsurance Program - Private Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	CMS-10321.ERRP Application	ERRP Hard Copy Application Draft 05_26_2010 (2).docx		Yes	No	Fillable Fileable
Instruction			ERRP Hard Copy Application Instructions Draft 05_26_2010.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: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
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

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.