Information Collection

Notice Requirements of the Health Care Continuation Coverage Provisions

IC 13504 under ICR 201406-1210-001 · OMB 1210-0123.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0123 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
modelgeneralnotice 5 1 14 230pm.doc	Other-COBRA Model General Notice
COBRA model election notice 5 1 14 230pm.docx	Other-COBRA Model Election Notice
ModelGeneralNoticeSP.doc	Other-COBRA Model General Notice Spa
ModelElectionNoticeSP.doc	Other-COBRA Model Election Notice Sp
COBRA notice NPRM 5 1 14 1215pm CLEAN.DOCX May 2014 COBRA NPRM	IC Document
no material change statement COBRA.docx No material/non-substative change justification	IC Document

IC Title:

Notice Requirements of the Health Care Continuation Coverage Provisions

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2590

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-COBRA Model General Notice	modelgeneralnotice 5 1 14 230pm.doc	Yes	No	Fillable Printable
Other-COBRA Model Election Notice	COBRA model election notice 5 1 14 230pm.docx	Yes	No	Fillable Printable
Other-COBRA Model General Notice Spanish	ModelGeneralNoticeSP.doc	Yes	No	Fillable Printable
Other-COBRA Model Election Notice Spanish	ModelElectionNoticeSP.doc	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 599,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	20,712,556	20,712,556
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	26,554,404	26,554,404

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
May 2014 COBRA NPRM	COBRA notice NPRM 5 1 14 1215pm CLEAN.DOCX	05/02/2014
No material/non-substative change justification	no material change statement COBRA.docx	06/10/2014

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