NOTICE OF ISSUANCE OF INSURANCE POLICY

ICR 198305-1215-004

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
122001 Migrated
ICR Details
1215-0059 198305-1215-004
Historical Active 198206-1215-010
DOL/ESA
NOTICE OF ISSUANCE OF INSURANCE POLICY
Revision of a currently approved collection   No
Regular
Approved without change 06/27/1983
Retrieve Notice of Action (NOA) 05/26/1983
  Inventory as of this Action Requested Previously Approved
05/31/1986 05/31/1986 05/31/1983
5,000 0 505
833 0 42
0 0 0

THE CM-921 PROVIDES INSURANCE CARRIERS WITH THE MEANS TO SUPPLY DCMWC WITH INFORMATION WHICH SHOWS THAT A RESPONSIBLE COAL MINE OPERATOR IS INSURED PURSUANT TO THE REQUIREMENTS SET FORTH BY THE BLACK LUNG BENEFITS REFORM ACT OF 1972.

None
None


No

1
IC Title Form No. Form Name
NOTICE OF ISSUANCE OF INSURANCE POLICY ESA/BL, 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 5,000 505 0 0 4,495 0
Annual Time Burden (Hours) 833 42 0 0 791 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.
05/26/1983


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