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Federal forms, ICRs, and supporting documents

Information Collection

Notice Requirements of the Health Care Continuation Coverage Provisions

IC 13504 under ICR 202004-1210-004 · OMB 1210-0123.

Documents and Forms
Document Name
Document Type
Other-COBRA Model General Notice
Other-COBRA Model Election Notice
Other-COBRA Model General Notice Spa
Other-COBRA Model Election Notice Sp
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Notice Requirements of the Health Care Continuation Coverage Provisions
 
No Modified
 
Required to Obtain or Retain Benefits
 
29 CFR 2590

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-COBRA Model General Notice model-general-notice amendment 4.27.20 DOL clearance.docx Yes No Fillable Printable
Other-COBRA Model Election Notice model-election-notice DOL 4.27 DOL Clearance.docx Yes No Fillable Printable
Other-COBRA Model General Notice Spanish model-general-notice-spanish (2).docx Yes No Fillable Printable
Other-COBRA Model Election Notice Spanish model-election-notice-spanish (2).docx Yes No Fillable Printable

Income Security General Retirement and Disability

 

660,653 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 18,128,968 0 0 0 0 18,128,968
Annual IC Time Burden (Hours) 0 0 0 0 0 0
Annual IC Cost Burden (Dollars) 37,133,409 0 0 0 0 37,133,409

Title Document Date Uploaded
FAQs About COBRA Model Notices FAQs ABOUT COBRA MODEL NOTICES Clean.docx 04/29/2020
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.