Additional Information Request to Plan Administrator

Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0135 can be found here:

Documents and Forms

Document Name Document Type
Form EBSA 301 Additional Information Request to Plan Administrator Form and Instruction
EBSA 301 Plan Sponsor/Plan Administrator Information Sheet Plan Sponsor-Plan Administrator Information Sheet41610.doc Form and Instruction
EBSA301-E-1 Letter to ER2010.doc Plan Sponsor Information Sheet IC Document

Information Collection (IC) Details

IC Title:	Additional Information Request to Plan Administrator	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	EBSA 301	Plan Sponsor/Plan Administrator Information Sheet	Plan Sponsor-Plan Administrator Information Sheet41610.doc		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,400	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	Previously Approved
Annual Number of Responses for this IC	1,400	1,400
Annual IC Time Burden (Hours)	350	350
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Plan Sponsor Information Sheet	EBSA301-E-1 Letter to ER2010.doc	03/15/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.