Information Collection

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

IC 188224 under ICR 200909-1210-003 · OMB 1210-0135.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form EBSA Form 300 Application to the U. S. 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	Form and Instruction
Form EBSA 301 Plan Sponsor/Plan Administrator Information Sheet Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction	Form
EBSA Form 300 Application to the U. S. Department of Labor for Expedit COBRAapplication5212009forinhouseprinting.pdf	Form and Instruction
EBSA 301 Plan Sponsor/Plan Administrator Information Sheet Plan Sponsor Sheet.doc	Form

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
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

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 30 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	14,000	-81,000	95,000
Annual IC Time Burden (Hours)	14,000	-81,000	95,000
Annual IC Cost Burden (Dollars)	8,000	-44,000	52,000

Documents for IC

table that charts IC Documents
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.