Notice of Issuance of Insurance Policy

ICR 199801-1215-002

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
13698 Migrated
ICR Details
1215-0059 199801-1215-002
Historical Active 199410-1215-003
DOL/ESA
Notice of Issuance of Insurance Policy
Extension without change of a currently approved collection   No
Regular
Approved without change 03/13/1998
Retrieve Notice of Action (NOA) 01/14/1998
  Inventory as of this Action Requested Previously Approved
03/31/2001 03/31/2001 03/31/1998
4,000 0 6,000
667 0 1,000
2,000 0 0

The CM-921 provides insurance carriers with the means to supply DCMWC with information showing that a responsible coal mine operator is insured against its Federal Black Lung compensation liability pursuant to the requirements established in the Federal Black Lung Benefits Act.

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 4,000 6,000 0 0 -2,000 0
Annual Time Burden (Hours) 667 1,000 0 0 -333 0
Annual Cost Burden (Dollars) 2,000 0 0 2,000 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.
01/14/1998


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