Information Collection List

IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.	Form Name
Employer Coverage Under an Employer Group Health Plan	New	800	133	0	Form and Instruction	RL-311-F (12-05)	Evidence of Coverage Under an Employee Group Health Plan
Employer Coverage Under an Employer Group Health Plan	New	800	133	0	Form and Instruction	RL-311-F (proposed)	Evidence of Coverage Under a Group Health Plan
Medicare	Modified	240	32	0	Form and Instruction	AA-6 (01-03)	Employee Application for Medicare
					Form and Instruction	AA-7 (01-03)	Spouse/Divorced Spouse Application for Medicare
					Form and Instruction	AA-8 (01-03)	Widow/Widower Application for Medicare
Total burden requested under this ICR:		1040	165	0
To view an IC, click on IC Title