Premium Payment (2010)

Application for Coverage in the Pre-Existing Condition Insurance Plan

OMB: 0938-1095

IC ID: 193400

Information Collection (IC) Details

View Information Collection (IC)

Premium Payment (2010)
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10334 PreExistingConditionPlan_EnrollmentForm_Spanish_508 PreExistingConditionPlan_EnrollmentForm_Spanish_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10334 CMS-10334.DRAFT Federal fallback enrollment form CMS-10334.DRAFT Federal fallback enrollment form.pdf Yes No Fillable Fileable

Health Health Care Services

 

50,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 50,000 0 0 0 0 50,000
Annual IC Time Burden (Hours) 8,000 0 0 0 0 8,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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