Information Collection

Early Retiree Reinsurance Program - Private Application

IC 192755 under ICR 201106-0938-023 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10321 Early Retiree Reinsurance Program - Private Application Form
0938-1087.Deliberative Document.docx Instruction
CMS-10321 Deliberative Document 0938-1087.Deliberative Document.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Early Retiree Reinsurance Program - Private Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	Deliberative Document	0938-1087.Deliberative Document.docx		Yes	No	Fillable Fileable
Instruction			0938-1087.Deliberative Document.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Early Retirement Reinsurance Program	FR Citation: 75 FR 31440

Number of Respondents: 4,125	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 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-4,125	4,125
Annual IC Time Burden (Hours)	-90,750	90,750
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.