Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act

ICR 200402-1215-001

OMB: 1215-0202

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
1215-0202 200402-1215-001
Historical Active
DOL/ESA
Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 06/08/2004
Retrieve Notice of Action (NOA) 02/19/2004
  Inventory as of this Action Requested Previously Approved
06/30/2007 06/30/2007
80 0 0
40 0 0
0 0 0

Information collected using Form CA-278 will allow OWCP to consider requests filed by insurance carriers and self-insured who have paid benefits to workers injured due to a war-risk hazard to be reimbursed for such benefits out of the Employees' Compensation Fund.

None
None


No

1
IC Title Form No. Form Name
Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act CA-278

  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 80 0 0 80 0 0
Annual Time Burden (Hours) 40 0 0 40 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
02/19/2004


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