Notice of Issuance of Insurance Policy

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-921 Notice of Issuance of Insurance Policy	Form and Instruction	Modified	Repair queued
30 USC 933.pdf	Supplementary Document	Uploaded 2007-01-10	Available
DOL-ESA 6.doc	Supplementary Document	Uploaded 2007-01-10	Available
20 CFR Part V Subpart C 726.208-213.doc	Supplementary Document	Uploaded 2007-01-09	Available
ss 1215-0059 1-10-2007.doc	Supporting Statement A	Uploaded 2007-01-10	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13700	Notice of Issuance of Insurance Policy	Form and Instruction	Modified

ICR Details

OMB Control No: 1215-0059	ICR Reference No: 200610-1215-001
Status: Historical Active	Previous ICR Reference No: 200312-1215-003
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Notice of Issuance of Insurance Policy
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/17/2007
	Date Received in OIRA: 01/19/2007
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2010	36 Months From Approved	04/30/2007
Responses	4,000	0	4,000
Time Burden (Hours)	667	0	667
Cost Burden (Dollars)	1,880	0	2,000

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Abstract: The CM-921 provides insurance carriers with the means to supply DCMWC with information showing that a responsible coal mine operator is insured against liability for payment of compensation under the Federal Black Lung Benefits Act.

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Authorizing Statute(s): US Code: 30 USC 933 Section 423 Name of Law: The Black Lung Benefits Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 58432	10/03/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 2559	01/19/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Notice of Issuance of Insurance Policy	CM-921, CM-921	Instructions for Completion of Form CM-921 ,   Instructions for Completion of Form CM-921

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ICR Summary of Burden

table that charts list of burden

	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	4,000	0	0	0	0
Annual Time Burden (Hours)	667	667	0	0	0	0
Annual Cost Burden (Dollars)	1,880	2,000	0	0	-120	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $9,327

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 01/19/2007

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