ERRP Prima Facie Evidence Cover Sheet

ERRP Prima Facie Evidence Cover Sheet.pdf

Early Retiree Reinsurance Program

ERRP Prima Facie Evidence Cover Sheet

OMB: 0938-1087

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EARLY RETIREE REINSURANCE PROGRAM
PRIMA FACIE EVIDENCE COVER SHEET ‐ DRAFT
1) Plan Sponsor Name:

2) Application ID: 

3) Plan Year Start Date: 

4) Plan Year End Date: 

5) Number of Pages Including Cover Sheet:

6) Today's Date:

7) Contact Name:

8) Contact Phone:

9) Information from Summary Cost Data Page of ERRP Secure Website
  a) Reimbursement Request #:
  b) Current Cost Paid by Early Retiree:
  c) Old Cost Paid by Early Retiree:
  d) Net Cost Paid by Early Retiree:
  e) Reimbursement Request Date:
  f) Reimbursement Request Total:

DETAIL
10)  Receipt Identifier

11) Claim Number

12) Cost Paid by Early Retiree

13) Member ID 

14) Member Group ID 

15) Provider ID 


File Typeapplication/pdf
File TitlePrima Facie Evidence Cover Sheet.xlsx
Authorp3fj
File Modified2011-06-16
File Created2011-06-16

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