Download:
pdf |
pdfWriting Agents Information Sheet
Compensation Structure:
Unique Identifying number
Not Applicable
Number of agents covered by compensation structure
Plan Contracted Marketing Organization Information Sheet
Compensation
Structure: Unique
Identifying number
Number of agents
covered by
compensation structure Full Name
Marketing Organization Name
Street Address
City
State
ZIP Code
Contact Name
Contact Phone # (include area code)
Contact Email
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0964 (expires 10/18). The time required to complete this information
collection is estimated to average 49 hours per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.
| File Type | application/pdf |
| Author | Chevell L. Thomas |
| File Modified | 2017-12-04 |
| File Created | 2017-12-04 |