Request for Coverage Determination

OMB 1212-0072

OMB 1212-0072

This form is used by a plan administrator or plan sponsor of a plan to request that the Pension Benefit Guaranty Corporation determine whether a plan is covered under title IV of the Employee Retirement Income Security Act of 1974.

The latest form for Request for Coverage Determination expires 2022-06-30 and can be found here.

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