Information Collection

Summary of Benefits and Coverage

IC 198888 under ICR 201202-1210-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form New Summary of Benefits and Coverage	Form
2715_Deliberative_Document[(20120207).docx	Instruction
2715_Deliberative_Document[(20120207).docx	Instruction
2715_Deliberative_Document[(20120207).docx	Other-Model
2715_Deliberative_Document[(20120207).docx	Other-Model
2715_Deliberative_Document[(20120207).docx	Other-Model
New Summary of Benefits and Coverage (SBC) Template 2715_Deliberative_Document[(20120207).docx	Form
2715_Deliberative_Document[(20120207).docx Sample Completed SBC-Individual Health Insurance Coverage	IC Document

IC Title:

Summary of Benefits and Coverage

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590.715-2715

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	New	Summary of Benefits and Coverage (SBC) Template	2715_Deliberative_Document[(20120207).docx	Yes	Yes	Fillable Printable
Instruction			2715_Deliberative_Document[(20120207).docx	Yes	Yes	Paper Only
Instruction			2715_Deliberative_Document[(20120207).docx	Yes	Yes	Paper Only
Other-Model			2715_Deliberative_Document[(20120207).docx	Yes	Yes	Paper Only
Other-Model			2715_Deliberative_Document[(20120207).docx	Yes	Yes	Paper Only
Other-Model			2715_Deliberative_Document[(20120207).docx	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: 44 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	77,000,000	77,000,000
Annual IC Time Burden (Hours)	602,750	602,750
Annual IC Cost Burden (Dollars)	4,150,000	4,150,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Sample Completed SBC-Individual Health Insurance Coverage	2715_Deliberative_Document[(20120207).docx	02/07/2012

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