Appendix A - Agents and Brokers - Data Elements for General Function of an Exchange (Part 155, Subpart C)

Information Collection Requirements for Non-Exchange Entities

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1329 can be found here:

Documents and Forms

Document Name Document Type
Appendix A - Agents and Brokers_.docx Instruction

Information Collection (IC) Details

IC Title:	Appendix A - Agents and Brokers - Data Elements for General Function of an Exchange (Part 155, Subpart C)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.220

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Appendix A - Agents and Brokers_.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 160	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	160	160
Annual IC Time Burden (Hours)	320	320
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.