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Information Collection

Evidence of Coverage under An Employer Group Health Plan

IC 34004 under ICR 199709-3220-002 · OMB 3220-0189.

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Information Collection (IC) Details

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Evidence of Coverage under An Employer Group Health Plan
 
No Migrated
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form RL-311-F No No


    

1,000 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,000 0 0 400 0 600
Annual IC Time Burden (Hours) 167 0 0 67 0 100
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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