NOTICE OF ISSUANCE OF INSURANCE POLICY

ICR 198206-1215-010

OMB: 1215-0059

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
168428 Migrated
ICR Details
1215-0059 198206-1215-010
Historical Active 197808-1215-005
DOL/ESA
NOTICE OF ISSUANCE OF INSURANCE POLICY
No material or nonsubstantive change to a currently approved collection   No
Emergency 06/30/1982
Approved with change 06/30/1982
Retrieve Notice of Action (NOA) 06/30/1982
  Inventory as of this Action Requested Previously Approved
05/31/1983 05/31/1983 05/31/1983
505 0 505
42 0 42
0 0 0

REPORT IS A REQUEST TO A MINE OPERATOR OR INSURANCE CARRIER OF WORKER'S COMPENSATION TO PROVIDE INFORMATION CONCERNING INSURANCE COVERAGE FOR BLACK LUNG CLAIMANTS UNDER THE BLACK LUNG BENEFITS REFORM ACT OF 1972.

None
None


No

1
IC Title Form No. Form Name
NOTICE OF ISSUANCE OF INSURANCE POLICY CM-921

  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 505 505 0 0 0 0
Annual Time Burden (Hours) 42 42 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.
06/30/1982


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