OMB control number
Notice Requirements of the Health Care Continuation Coverage Provisions
OMB 1210-0123 · DOL/EBSA.
OMB 1210-0123
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provides that under certain circumstances participants and beneficiaries of group health plans that satisfy the definition of “qualified beneficiaries” under COBRA may elect to continue group health coverage temporarily following events known as “qualifying events” that would otherwise result in loss of coverage. Under the regulatory guidelines, plan administrators are required to distribute notices: a general notice to be distributed to all participants in group health plans subject to COBRA; an employer notice that must be completed by the employer upon the occurrence of a qualifying event; a notice and election form to be sent to a participant upon the occurrence of a qualifying event that might cause the participant to lose group health coverage; an employee notice that may be completed by a qualified beneficiary upon the occurrence of certain qualifying events such as divorce or disability; and, two other notices, one of early termination and the other a notice of unavailability. Also included in the ICR are two model notices that the Department believes will help reduce costs for service providers in preparing and delivering notices to comply with the regulations.
The latest form for Notice Requirements of the Health Care Continuation Coverage Provisions expires 2029-07-31 and is listed under ICR 202508-1210-007.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
| Supporting Statement A | |
| Other-COBRA Model General Notice |