Information Collection

Proposed Annual Ongoing Costs Related to Agent and Broker Compensation Disclosure Provided with Enrollment Materials

IC 249382 under ICR 202109-0938-002 · OMB 0938-1403.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10787 - Appendix 1 - Agent and Broker Disclosure and Reporting Requirements Data Elements.pdf	Other-Data
CMS-10787 - Appendix 1 - Agent and Broker Disclosure and Reporting Requirements Data Elements.pdf	Other-Data

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 148.410(c)(5) 45 CFR 148.410(c)(2)(i)-(ii) 45 CFR 148.410(c)(3) 45 CFR 148.410(c)(4)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Data					Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,324

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: 95 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	4,440,971	4,440,971
Annual IC Time Burden (Hours)	244,453	244,453
Annual IC Cost Burden (Dollars)	856,268	856,268

Documents for IC

table that charts IC Documents
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.

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