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⚠️ Notice: This information collection may be referencing outdated material.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

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

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: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590.715-2715

Information Collection 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 %

	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

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.