Information Collection Request

Certificate of Coverage Request

ICR 202601-0960-004 · OMB 0960-0554 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Addendum - 0554 (Final).docx Supplementary Document Uploaded 2026-02-24 Available
Supporting Statement - 0554 (Final).docx Supporting Statement A Uploaded 2026-02-24 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
9477 Certificate of Coverage Request via Letter - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden, Uruguay, France, Japan, Belgium, and Poland) Instruction Modified
279197 Certificate of Coverage Request via Internet - Employers in Belgium Other-Certificate of Coverage Country Agreement New
279196 Certificate of Coverage Request via Letter - Employers in Belgium Other-Certificate of Coverage Country Agreement New
279195 Certificate of Coverage Request via Internet - Employers in France and Japan Other-Certificate of Coverage Country Agreement New
279194 Certificate of Coverage Request via Letter - Employers in France and Japan Other-Certificate of Coverage Country Agreement New
279193 Certificate of Coverage Request via Internet - Employers in Germany, Italy, Spain, Uruguay Other-Certificate of Coverage Country Agreement New
279192 Certificate of Coverage Request via Letter - Employers in Germany, Italy, Spain, Uruguay Other-Certificate of Coverage Country Agreement New
279187 Certificate of Coverage Request via Internet - Individuals in Belgium Other-Certificate of Coverage Country Agreement New
279186 Certificate of Coverage Request via Letter - Individuals in Belgium Other-Certificate of Coverage Country Agreement New
279126 Certificate of Coverage Request via Internet - Individuals in France and Japan Other-Internet Screens New
279124 Certificate of Coverage Request via Letter - Individuals in France and Japan Other-Internet Screens New
279122 Certificate of Coverage Request via Internet - Individuals in Germany, Italy, Spain, Uruguay Other-Internet Screens New
279121 Certificate of Coverage Request via Letter - Individuals in Germany, Italy, Spain, Uruguay Other-Internet Screens New
222537 Certificate of Coverage Request via Internet - Employers (Poland) Other-Certificate of Coverage Country Agreement Modified
222536 Certificate of Coverage Request via Letter - Employers (Poland) Other-Certificate of Coverage Country Agreement Modified
222535 Certificate of Coverage Request via Internet - Individuals (Poland) Other-Internet Screens Modified
222534 Certificate of Coverage Request via Letter - Individuals (Poland) Other-Certificate of Coverage Country Agreement Modified
206903 Certificate of Coverage Request via Internet - Employers in Denmark, Iceland, Netherlands, Norway, and Sweden Other-Internet Application Modified
206902 Certificate of Coverage Request via Letter - Employers in Denmark, Iceland, Netherlands, Norway, and Sweden Other-Certificate of Coverage Country Agreement Modified
206901 Certificate of Coverage Request via Internet - Employers (minus Denmark, Iceland, Netherlands, Norway, Sweden, Germany, Italy, Spain, Uruguay, France, Japan, Belgium, and Poland) Other-Internet Application Modified
206899 Certificate of Coverage Request via Letter - Employers (minus Denmark, Iceland, Netherlands, Norway, Sweden, Germany, Italy, Spain, Uruguay, France, Japan, Belgium, and Poland) Other-Certificate of Coverage Country Agreement Modified
206898 Certificate of Coverage Request via Internet - Individuals in Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden & Uruguay Other-Internet Application Modified
206897 Certificate of Coverage Request via Letter - Individuals in Denmark, Iceland, Netherlands, Norway, & Sweden) Instruction Modified
182116 Certificate of Coverage Request via Internet - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden, Uruguay, France, Japan, Belgium, and Poland) Other-Internet Application Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
04/30/2029 36 Months From Approved 04/30/2026
20,770 0 32,722
14,100 0 21,975
0 0 0





Reginfo record details
24
table that charts list of burden
IC Title Form No. Form Name
Certificate of Coverage Request via Internet - Employers (Poland)
Certificate of Coverage Request via Internet - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden, Uruguay, France, Japan, Belgium, and Poland)
Certificate of Coverage Request via Internet - Employers (minus Denmark, Iceland, Netherlands, Norway, Sweden, Germany, Italy, Spain, Uruguay, France, Japan, Belgium, and Poland)
Certificate of Coverage Request via Internet - Employers in Belgium
Certificate of Coverage Request via Internet - Employers in Denmark, Iceland, Netherlands, Norway, and Sweden
Certificate of Coverage Request via Internet - Employers in France and Japan
Certificate of Coverage Request via Internet - Employers in Germany, Italy, Spain, Uruguay
Certificate of Coverage Request via Internet - Individuals (Poland)
Certificate of Coverage Request via Internet - Individuals in Belgium
Certificate of Coverage Request via Internet - Individuals in Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden & Uruguay
Certificate of Coverage Request via Internet - Individuals in France and Japan
Certificate of Coverage Request via Internet - Individuals in Germany, Italy, Spain, Uruguay
Certificate of Coverage Request via Letter - Employers (Poland)
Certificate of Coverage Request via Letter - Employers (minus Denmark, Iceland, Netherlands, Norway, Sweden, Germany, Italy, Spain, Uruguay, France, Japan, Belgium, and Poland)
Certificate of Coverage Request via Letter - Employers in Belgium
Certificate of Coverage Request via Letter - Employers in Denmark, Iceland, Netherlands, Norway, and Sweden
Certificate of Coverage Request via Letter - Employers in France and Japan
Certificate of Coverage Request via Letter - Employers in Germany, Italy, Spain, Uruguay
Certificate of Coverage Request via Letter - Individuals (Poland)
Certificate of Coverage Request via Letter - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden, Uruguay, France, Japan, Belgium, and Poland)
Certificate of Coverage Request via Letter - Individuals in Belgium
Certificate of Coverage Request via Letter - Individuals in Denmark, Iceland, Netherlands, Norway, & Sweden)
Certificate of Coverage Request via Letter - Individuals in France and Japan
Certificate of Coverage Request via Letter - Individuals in Germany, Italy, Spain, Uruguay

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 20,770 32,722 0 -86 -11,866 0
Annual Time Burden (Hours) 14,100 21,975 0 -259 -7,616 0
Annual Cost Burden (Dollars) 0 0 0 -3,985 3,985 0


Reginfo record details
  No