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Federal forms, ICRs, and supporting documents

Information Collection

Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions

IC 13942 under ICR 200703-1215-003 · OMB 1215-0204.

Documents and Forms
Document Name
Document Type
Form
Form
Form
Form
IC Document
Information Collection (IC) Details

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Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 703.204 20 CFR 703.303 20 CFR 703.205 20 CFR 702.210 20 CFR 703.212 20 CFR 703.304 20 CFR 703.2 20 CFR 703.203 20 CFR 703.209

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form LS-275-IC Agreement and Undertaking (Insurance Carrier) LS-275ic.pdf http://www.dol.gov/esa/owcp/dlhwc/lsforms.htm No   Fillable Printable
Form LS-275-SI Agreement and Undertaking (Self-Insured Employer) LS-275si.pdf http://www.dol.gov/esa/owcp/dlhwc/lsforms.htm No   Fillable Printable
Form LS-276 Application for Security Deposit Determination LS-276.pdf http://www.dol.gov/esa/owcp/dlhwc/lsforms.htm No   Fillable Printable

Income Security Survivor Compensation

 

646 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 646 0 0 -82 0 728
Annual IC Time Burden (Hours) 434 0 0 -36 0 470
Annual IC Cost Burden (Dollars) 288 0 0 288 0 0

Title Document Date Uploaded
Note to Reviewer for 1215-0204 NOTE TO REVIEWER 1215-0204.doc 03/05/2007
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.