Notice of Enrollment Rights

ICR 200306-1210-009

OMB: 1210-0101

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
13441
Migrated
ICR Details
1210-0101 200306-1210-009
Historical Active 200003-1210-005
DOL/EBSA
Notice of Enrollment Rights
Extension without change of a currently approved collection   No
Regular
Approved without change 10/08/2003
Retrieve Notice of Action (NOA) 06/27/2003
  Inventory as of this Action Requested Previously Approved
10/31/2006 10/31/2006 10/31/2003
9,602,000 0 9,602,000
7,200 0 7,200
841,000 0 841,000

Under 29 CFR 2590.701-6, a group health plan offering group health insurance coverage is obligated to provide a description of the plan's special enrollment rules.

None
None


No

1
IC Title Form No. Form Name
Notice of Enrollment Rights

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 9,602,000 9,602,000 0 0 0 0
Annual Time Burden (Hours) 7,200 7,200 0 0 0 0
Annual Cost Burden (Dollars) 841,000 841,000 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/27/2003


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