Information Collection

Summary of Benefits and Coverage

IC 198888 under ICR 201411-1210-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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
blank template 12-19-14 FINAL.docx www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-SBC template
Instructions Group 12-19-14 FINAL.docx www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Instruction
Instructions Individual 12-19-14 FINAL.docx www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Instruction
Sample completed sbc 12-19-14 FINAL.doc Sample Completed SBC	IC Document
Why This Matters - No Answers FINAL.doc Why This Matters-No Answers	IC Document
Why This Matters - Yes Answers FINAL.doc Why This Matters-Yes Answers	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-SBC template	blank template 12-19-14 FINAL.docx	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	Yes	Fillable Fileable
Instruction	Instructions Group 12-19-14 FINAL.docx	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Fillable Fileable
Instruction	Instructions Individual 12-19-14 FINAL.docx	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,388,923

Number of Respondents for Small Entity: 2,248,000

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 38 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	60,647,341	-16,352,659	77,000,000
Annual IC Time Burden (Hours)	383,880	-218,870	602,750
Annual IC Cost Burden (Dollars)	7,487,784	3,337,784	4,150,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Sample Completed SBC	Sample completed sbc 12-19-14 FINAL.doc	12/19/2014
Why This Matters-No Answers	Why This Matters - No Answers FINAL.doc	12/19/2014
Why This Matters-Yes Answers	Why This Matters - Yes Answers FINAL.doc	12/19/2014

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