Information Collection

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

IC 188224 under ICR 201001-1210-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 301 Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction	Form
EBSA 301 Plan Sponsor/Plan Administrator Information Sheet Plan Sponsor Sheet.doc	Form
EBSA 300 Application to the U. S. Department of Labor for Expedit COBRAapplic011510.pdf	Form and Instruction

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	EBSA 301	Plan Sponsor/Plan Administrator Information Sheet	Plan Sponsor Sheet.doc		Yes	Yes	Fillable Printable
Form and Instruction	EBSA 300	Application to the U. S. Department of Labor for Expedited Review of Denial of COBRA Premium Reduction	COBRAapplic011510.pdf		Yes	Yes	Fillable Fileable

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	Previously Approved
Annual Number of Responses for this IC	14,000	14,000
Annual IC Time Burden (Hours)	14,000	14,000
Annual IC Cost Burden (Dollars)	8,000	8,000

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.