Model Cobra Continuation Coverage Election Notice (Page 8 of 8) in pdf

Model Cobra Continuation Coverage Election Notice Page 8

In order to protect your and your family’s rights, you should keep the Plan Administrator

informed of any changes in your address and the addresses of family members. You should also

keep a copy, for your records, of any notices you send to the Plan Administrator.

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are

required to respond to a collection of information unless such collection displays a valid Office

of Management and Budget (OMB) control number. The Department notes that a Federal

agency cannot conduct or sponsor a collection of information unless it is approved by OMB

under the PRA, and displays a currently valid OMB control number, and the public is not

required to respond to a collection of information unless it displays a currently valid OMB

control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no

person shall be subject to penalty for failing to comply with a collection of information if the

collection of information does not display a currently valid OMB control number. See 44 U.S.C.

3512.

The public reporting burden for this collection of information is estimated to average

approximately four minutes per respondent. Interested parties are encouraged to send comments

regarding the burden estimate or any other aspect of this collection of information, including

suggestions for reducing this burden, to the U.S. Department of Labor, Office of the Chief

Information Officer, Attention: Departmental Clearance Officer, 200 Constitution Avenue,

N.W., Room N-1301, Washington, DC 20210 or email DOL_PRA_PUBLIC@dol.gov and

reference the OMB Control Number 1210-0123.

OMB Control Number 1210-0123 (expires 09/30/2013)

Model Cobra Continuation Coverage Election Notice Page 8