Health Insurance Claim Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0044 can be found here:

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Insurance Claim Form	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
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
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

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 %

	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

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.