Information Collection

Notice Requirements of the Health Care Continuation Coverage Provisions

IC 13504 under ICR 202210-1210-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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
model-general-notice amendment 4.27.20 DOL clearance.docx	Other-COBRA Model General Notice
model-general-notice amendment 4.27.20 DOL clearance.docx	Other-COBRA Model General Notice
model-election-notice DOL 4.27 DOL Clearance.docx	Other-COBRA Model Election Notice
model-election-notice DOL 4.27 DOL Clearance.docx	Other-COBRA Model Election Notice
model-general-notice-spanish (2).docx	Other-COBRA Model General Notice Spa
model-general-notice-spanish (2).docx	Other-COBRA Model General Notice Spa
model-election-notice-spanish (2).docx	Other-COBRA Model Election Notice Sp
model-election-notice-spanish (2).docx	Other-COBRA Model Election Notice Sp
FAQs ABOUT COBRA MODEL NOTICES Clean.docx FAQs About COBRA Model Notices	IC Document
FAQs ABOUT COBRA MODEL NOTICES Clean.docx FAQs About COBRA Model Notices	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	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

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,981,055

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	26,890,373	8,761,405	18,128,968
Annual IC Time Burden (Hours)	490,857	490,857	0
Annual IC Cost Burden (Dollars)	16,403,128	-20,730,281	37,133,409

Documents for IC

table that charts IC Documents
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.