Information Collection

COBRA Notification Requirements--American Recovery and Reinvestment Act of 2009

IC 188172 under ICR 200902-1210-004 · OMB 1210-0123.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Final model general notice - full version.doc	Other- ARRA Model COBRA Initial Elec
Final model general notice - abbreviated version.doc	Other-ARRA Model COBRA Supplemental
Final model notice in connection with extended election periods.doc	Other-ARRA Model COBRA Second Electi
Final model alternative notice.doc	Other-ARRA Model COBRA Notice for No
ARRA models FR notice 3-13-09.doc ARRA COBRA Model Notice Federal Register Notice	IC Document

IC Title:

COBRA Notification Requirements--American Recovery and Reinvestment Act of 2009

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 2590.606(a)

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other- ARRA Model COBRA Initial Election Notice	Final model general notice - full version.doc	Yes	No	Printable Only
Other-ARRA Model COBRA Second Election Notice	Final model notice in connection with extended election periods.doc	Yes	No	Printable Only
Other-ARRA Model COBRA Notice for Non-ERISA Plans	Final model alternative notice.doc	Yes	No	Printable Only
Other-ARRA Model COBRA Supplemental Notice for Current Enrolles	Final model general notice - abbreviated version.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: 2,500,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	22,877,000	22,877,000
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	16,112,734	16,112,734

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ARRA COBRA Model Notice Federal Register Notice	ARRA models FR notice 3-13-09.doc	03/13/2009

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