Additional Information Request to Plan Administrator

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0135 can be found here:

Documents and Forms

Document Name Document Type
Form EBSA Form 301 Additional Information Request to Plan Administrator Form and Instruction
EBSA Form 301 Request for Additonal Information from Plan Administrato Letter E Request for info to PA-May 14[1].doc Form and Instruction

Information Collection (IC) Details

IC Title:	Additional Information Request to Plan Administrator	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	EBSA Form 301	Request for Additonal Information from Plan Administrator	Letter E Request for info to PA-May 14[1].doc		No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,500	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	Program Change Due to New Statute
Annual Number of Responses for this IC	9,500	9,500
Annual IC Time Burden (Hours)	4,750	4,750
Annual IC Cost Burden (Dollars)	0	0

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.