Information Collection

Notice of Special Enrollment Rights under Group Health Plans

IC 38418 under ICR 202504-1210-004 · OMB 1210-0101.

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IC Title:	Notice of Special Enrollment Rights under Group Health Plans	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590.701-6 29 CFR 2520.104b-1

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,588,300	Number of Respondents for Small Entity: 2,277,704

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

Percentage of Respondents Reporting Electronically: 58 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,585,910	1,967,147	8,618,763
Annual IC Time Burden (Hours)	0	-552	552
Annual IC Cost Burden (Dollars)	110,358	-320,580	430,938

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