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

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

OMB: 1210-0135

IC ID: 188224

Information Collection (IC) Details

View Information Collection (IC)

Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction EBSA Form 300 Application to the U. S. Department of Labor for Expedited Review of Denial of COBRA Premium Reduction COBRAapplication5212009forinhouseprinting.pdf Yes Yes Fillable Printable
Form EBSA 301 Plan Sponsor/Plan Administrator Information Sheet Plan Sponsor Sheet.doc Yes Yes Fillable Printable

Income Security General Retirement and Disability

 

14,000 0
   
Individuals or Households
 
   30 %

  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 14,000 0 0 -81,000 0 95,000
Annual IC Time Burden (Hours) 14,000 0 0 -81,000 0 95,000
Annual IC Cost Burden (Dollars) 8,000 0 0 -44,000 0 52,000

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