Information Collection Request

Certificate of Coverage Request

ICR 201607-0960-003 · OMB 0960-0554 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Addendum - 0554.docx Supplementary Document Uploaded 2016-09-30 Available
Supporting Statement - 0554.docx Supporting Statement A Uploaded 2016-09-30 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
9477 Certificate of Coverage Request via Letter - Individuals (minus Denmark, Netherlands, Norway, & Sweden) Instruction Unchanged
222537 Certificate of Coverage Request Internet- Employers (Poland) Instruction New
222536 Certificate of Coverage Request via Letter - Employers (Poland) Instruction New
222535 Certificate of Coverage Request via Letter -Internet- Individuals (Poland) Other-Internet Screens New
222534 Certificate of Coverage Request via Letter - Individuals (Poland) Instruction New
206903 Certificate of Coverage Request via Internet - Employers in Denmark, Netherlands, Norway, & Sweden Other-Internet Application Modified
206902 Certificate of Coverage Request via Letter - Employers in Denmark, Netherlands, Norway, & Sweden Instruction Unchanged
206901 Certificate of Coverage Request via Internet - Employers (minus Denmark, Netherlands, Norway, & Sweden) Other-Internet Application Modified
206899 Certificate of Coverage Request via Letter - Employers (minus Denmark, Netherlands, Norway, & Sweden) Instruction Unchanged
206898 Certificate of Coverage Request via Internet - Individuals in Denmark, Netherlands, Norway, & Sweden Other-Internet Application Modified
206897 Certificate of Coverage Request via Letter - Individuals in Denmark, Netherlands, Norway, & Sweden Instruction Unchanged
182116 Certificate of Coverage Request via Internet - Individuals (minus Denmark, Netherlands, Norway, & Sweden) Other-Revised PA Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
12/31/2019 36 Months From Approved 12/31/2016
82,094 0 81,900
54,966 0 54,833
0 0 0





table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 82,094 81,900 0 194 0 0
Annual Time Burden (Hours) 54,966 54,833 0 133 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No