Information Collection

Summary of Benefits and Coverage

IC 198888 under ICR 201108-1210-005 · OMB 1210-0147.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0147 can be found here:

Documents and Forms

Document Name Document Type
Form NEW Summary of Benefits and Coverage Form
SBCInstructionsGroup.pdf www.dol.gov/ebsa/pdf/SBCInstructionsGroup.pdf Instruction
SBCInstructionsIndividual.pdf www.dol.gov/ebsa/pdf/SBCInstructionsIndividual.pdf Instruction
SBCYesAnswers.pdf www.dol.gov/ebsa/pdf/SBCYesAnswers.pdf Other-Model
SBCNoAnswers.pdf www.dol.gov/ebsa/pdf/SBCNoAnswers.pdf Other-Model
NEW Summary of Benefits and Coverage (SBC) Template SBCtemplate.pdf www.dol.gov/ebsa/pdf/SBCtemplate.pdf Form
SBCSampleCompleted.pdf Sample Completed SBC - Individual Health Insurance Coverage IC Document
SBCCoverageGuide.xls Guide for Coverage Examples Calculations IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Summary of Benefits and Coverage	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590.715-2715

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NEW	Summary of Benefits and Coverage (SBC) Template	SBCtemplate.pdf	http://www.dol.gov/ebsa/pdf/SBCtemplate.pdf	Yes	Yes	Fillable Printable
Instruction			SBCInstructionsGroup.pdf	http://www.dol.gov/ebsa/pdf/SBCInstructionsGroup.pdf	Yes	Yes	Paper Only
Instruction			SBCInstructionsIndividual.pdf	http://www.dol.gov/ebsa/pdf/SBCInstructionsIndividual.pdf	Yes	Yes	Paper Only
Other-Model			SBCYesAnswers.pdf	http://www.dol.gov/ebsa/pdf/SBCYesAnswers.pdf	Yes	Yes	Paper Only
Other-Model			SBCNoAnswers.pdf	http://www.dol.gov/ebsa/pdf/SBCNoAnswers.pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 858	Number of Respondents for Small Entity: 274

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 38 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	77,000,000	77,000,000
Annual IC Time Burden (Hours)	630,000	630,000
Annual IC Cost Burden (Dollars)	4,350,007	4,350,007

Documents for IC

Title	Document	Date Uploaded
Sample Completed SBC - Individual Health Insurance Coverage	SBCSampleCompleted.pdf	08/19/2011
Guide for Coverage Examples Calculations	SBCCoverageGuide.xls	08/19/2011

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