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 2520.104b-1 29 CFR 2590.701-6

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: 2,953,935	Number of Respondents for Small Entity: 2,765,373

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

Percentage of Respondents Reporting Electronically: 58 %

	Approved	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)	1,010	458	552
Annual IC Cost Burden (Dollars)	110,358	-320,580	430,938

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