Additional Information Request to Plan Administrator

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

Documents and Forms

Document Name Document Type
Form Form 301 Additional Information Request to Plan Administrator Form and Instruction
Form 301 Plan Sponsor/Plan Administrator Information Sheet Plan_Sponsor-Plan_Administrator_Information_Sheet41610[1].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	Form 301	Plan Sponsor/Plan Administrator Information Sheet	Plan_Sponsor-Plan_Administrator_Information_Sheet41610[1].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: 17	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	17	-1,383	1,400
Annual IC Time Burden (Hours)	4	-346	350
Annual IC Cost Burden (Dollars)	0	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.