Notice Requirements of the Health Care Continuation Coverage Provisions

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0123 can be found here:

Documents and Forms

Document Name Document Type
modelgeneralnotice.doc Other-Model General Notice
modelelectionnotice.doc Other-Model Election Notice

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Notice Requirements of the Health Care Continuation Coverage Provisions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2590

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model General Notice			modelgeneralnotice.doc		Yes	No	Fillable Printable
Other-Model Election Notice			modelelectionnotice.doc		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 599,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20,712,556	5,050,223	15,662,333
Annual IC Time Burden (Hours)	0	-503,815	503,815
Annual IC Cost Burden (Dollars)	26,554,404	6,336,626	20,217,778

Documents for IC

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.