APPLICATION FOR SELF-INSURANCE

ICR 198006-1215-001

OMB: 1215-0062

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
168436 Migrated
ICR Details
1215-0062 198006-1215-001
Historical Active 198005-1215-002
DOL/ESA
APPLICATION FOR SELF-INSURANCE
No material or nonsubstantive change to a currently approved collection   No
Emergency 06/18/1980
Approved with change 06/18/1980
Retrieve Notice of Action (NOA) 06/18/1980
  Inventory as of this Action Requested Previously Approved
04/30/1984 04/30/1984 04/30/1988
15 0 15
120 0 120
0 0 0

REPORT IS THE BASIC FORM USED BY ALL COAL MINE OPERATORS SEEKING AUTHORITY FROM DOL TO SELF-INSURE THEIR LIABILITIES UNDER THE FEDERAL MINE SAFETY AND HEALTH ACT OF 1977.

None
None


No

1
IC Title Form No. Form Name
APPLICATION FOR SELF-INSURANCE CM-920

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 15 15 0 0 0 0
Annual Time Burden (Hours) 120 120 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/18/1980


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