Information Collection

Summary of Benefits and Coverage

IC 198888 under ICR 201502-1210-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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: 2,388,923

Number of Respondents for Small Entity: 2,248,196

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	60,647,341	-16,352,659	77,000,000
Annual IC Time Burden (Hours)	371,864	-230,886	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	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.