Information Collection

Health Insurance Claim Form

IC 43805 under ICR 200907-1215-001 · OMB 1215-0055.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OWCP-1500 Health Insurance Claim Form	Form
OWCP-1500 Health Insurance Claim Form OWCP-1500 draft for 2009 clearance (08-10-2009).pdf www.dol.gov/esa/regs/complainace/owcp/eeoicp/claimsform.htm	Form
OWCP-1500 Health Insurance Claim Form OWCP-1500 Pages 2-3 (Instructions) (2009 clearance).doc www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsform.htm	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 725.405 20 CFR 725.701 20 CFR 10.801 20 CFR 30.701 20 CFR 725.704

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-1500	Health Insurance Claim Form	OWCP-1500 Pages 2-3 (Instructions) (2009 clearance).doc	http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsform.htm	Yes	No	Fillable Printable
Form	OWCP-1500	Health Insurance Claim Form	OWCP-1500 draft for 2009 clearance (08-10-2009).pdf	http://www.dol.gov/esa/regs/complainace/owcp/eeoicp/claimsform.htm	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: DOL/GOVT-1(FECA); DOL/ESA-6(BLBA); DOL/ESA-49EEOICPA

FR Citation: 67 FR 16821

Number of Respondents: 749,104

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,996,416	56,416	2,940,000
Annual IC Time Burden (Hours)	359,359	16,451	342,908
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.