Information Collection

Notice Requirements of the Health Care Continuation Coverage Provisions

IC 13504 under ICR 202508-1210-007 · OMB 1210-0123.

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-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-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

IC Title:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-COBRA Model General Notice	Yes	No	Fillable Printable
Other-COBRA Model Election Notice	Yes	No	Fillable Printable
Other-COBRA Model General Notice Spanish	Yes	No	Fillable Printable
Other-COBRA Model Election Notice Spanish	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: 750,213

Number of Respondents for Small Entity: 596,551

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
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	24,351,126	-2,539,247	26,890,373
Annual IC Time Burden (Hours)	524,890	34,033	490,857
Annual IC Cost Burden (Dollars)	19,237,389	2,834,261	16,403,128

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
FAQs About COBRA Model Notices		04/29/2020

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

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