Information Collection

Summary of Benefits and Coverage

IC 198888 under ICR 201304-1210-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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
SBC blank template 4-23-13 10am.doc	Other-Sample SBC
SBCInstructionsGroup[1].pdf	Instruction
SBCInstructionsIndividual.pdf	Instruction
SBCUniformGlossary.pdf	Other-SBC Sample Glossary
SBCYesAnswers.pdf	Other-SBC Yes Answers -- Why This Ma
SBCNoAnswers.pdf	Other-SBC - No Answers - Why This Ma
SampleCompletedSBC 4-23-13 10am.doc Sample Completed SBC	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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Sample SBC	SBC blank template 4-23-13 10am.doc	Yes	No	Fillable Fileable
Instruction	SBCInstructionsGroup[1].pdf	Yes	No	Printable Only
Instruction	SBCInstructionsIndividual.pdf	Yes	No	Printable Only
Other-SBC Sample Glossary	SBCUniformGlossary.pdf	Yes	No	Printable Only
Other-SBC Yes Answers -- Why This Matters	SBCYesAnswers.pdf	Yes	No	Printable Only
Other-SBC - No Answers - Why This Matters	SBCNoAnswers.pdf	Yes	No	Printable 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	Previously Approved
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	SampleCompletedSBC 4-23-13 10am.doc	04/23/2013

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