Information Collection

Employer Coverage Under an Employer Group Health Plan

IC 186948 under ICR 202606-3220-013 · OMB 3220-0082.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form RL-311F (08-22) Cu Evidence of Coverage Under an Employee Group Health Plan Employer Coverage Under an Employer Group Health Plan	Form and Instruction
Form RL-311F (08-22) Cu Evidence of Coverage Under an Employee Group Health Plan Employer Coverage Under an Employer Group Health Plan	Form and Instruction
Form RL-311F (XX-XX) Pr Evidence of Coverage Under an Employee Group Health Plan Employer Coverage Under an Employer Group Health Plan	Form and Instruction
Form RL-311F (XX-XX) Pr Evidence of Coverage Under an Employee Group Health Plan Employer Coverage Under an Employer Group Health Plan	Form and Instruction
RL-311F (08-22) Cu Evidence of Coverage Under an Employee Group Health Plan Form RL-311F (08-22).pdf	Form and Instruction
RL-311F (08-22) Cu Evidence of Coverage Under an Employee Group Health Plan Form RL-311F (08-22).pdf	Form and Instruction
RL-311F (XX-XX) Pr Evidence of Coverage Under an Employee Group Health Plan Form RL-311F Evidence of Coverage Under An Employer Group Health Plan (XX-XX) Proposed.pdf	Form and Instruction
RL-311F (XX-XX) Pr Evidence of Coverage Under an Employee Group Health Plan Form RL-311F Evidence of Coverage Under An Employer Group Health Plan (XX-XX) Proposed.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 406 42 CFR 407

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	RL-311F (08-22) Current				No		Paper Only
Form and Instruction	RL-311F (XX-XX) Proposed				No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: RRB-20, Health Insurance and Supplementary Medical Insurance Enrollment and Premium Payment System (MEDICARE)

FR Citation: 79 FR 58874

Number of Respondents: 2,000

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	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	333	333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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