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Federal forms, ICRs, and supporting documents

Information Collection

Health Insurance Claim Form

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

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

View Information Collection (IC)

Health Insurance Claim Form
 
No Modified
 
Voluntary
 
20 CFR 725.405 20 CFR 725.701 20 CFR 10.801 20 CFR 30.701 20 CFR 725.704

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

Health Health Care Services

DOL/GOVT-1(FECA); DOL/ESA-6(BLBA); DOL/ESA-49EEOICPA   67 FR 16821

749,104 0
   
Private Sector 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 2,996,416 0 0 56,416 0 2,940,000
Annual IC Time Burden (Hours) 359,359 0 0 16,451 0 342,908
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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