Get Early Retiree Reinsurance Program Application

The Early Retiree Reinsurance Program Application is an essential document for organizations seeking reimbursement for health benefits provided to early retirees. This guide will help you navigate the online application process effectively and ensure that all required fields are accurately completed.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the Early Retiree Reinsurance Program Application form. This will open the document for you to fill online.
2. Begin with Part I, which requires information about the organization. Fill in the organization's name, type, Employer Identification Number (EIN), and contact details. Make sure that the name corresponds with the EIN records.
3. Continue to fill in the Authorized Representative Information. Provide the full name, job title, email address, and employer name of the representative filling out the application.
4. Next, complete the Account Manager Information section. Similar information as the previous step is required. Ensure accuracy in personal details and company affiliation.
5. Proceed to Part II, where you will provide Plan Information. Input the plan name, the plan year cycle dates, and detail any benefit options being offered.
6. In the section regarding Chronic and High-Cost Conditions, identify any relevant conditions and summarize the programs your organization has in place for these participants.
7. Fill in the Estimated Amount of Early Retiree Reinsurance Program Reimbursements, providing low-end, most likely, and high-end estimates for reimbursements.
8. Complete the Intended Use of Reimbursements section, explaining how the reimbursement will help in reducing costs for the organization and plan participants.
9. In Part III, provide Banking Information for Electronic Funds Transfer, including bank name, address, and account details.
10. Finally, review and sign the Plan Sponsor Agreement in Part IV, confirming compliance and accuracy of the information provided.
11. Once all sections are completed, you can save your changes and choose to download, print, or share the form as necessary.

Complete your application online to ensure a smooth and efficient reimbursement process.