Information Collection

Notice of Issuance of Insurance Policy

IC 13700 under ICR 201003-1240-048 · OMB 1240-0048.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0048 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-921 Notice of Issuance of Insurance Policy	Form and Instruction
CM-921 Instructions for Completion of Form CM-921 CM-921 form and instructions.pdf www.dol.gov/esa/regs/compliance/owcp/cm-921.pdf	Form and Instruction
CM-921 Instructions for Completion of Form CM-921 CM-921 form and Instructions draft 9-20-06.pdf www.dol.gov/esa/regs/compliance/owcp/cm-921.pdf	Form and Instruction
Note to Reviewers CM-921 (Sep 2006).pdf Notice to Reviewer	IC Document

IC Title:

Notice of Issuance of Insurance Policy

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 726.208 -.213 20 CFR 726.206

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	CM-921	Instructions for Completion of Form CM-921	CM-921 form and instructions.pdf	http://www.dol.gov/esa/regs/compliance/owcp/cm-921.pdf	Yes	No	Fillable Printable
Form and Instruction	CM-921	Instructions for Completion of Form CM-921	CM-921 form and Instructions draft 9-20-06.pdf	http://www.dol.gov/esa/regs/compliance/owcp/cm-921.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: DOL/ESA-6

FR Citation: 67 FR 16869

Number of Respondents: 4,000

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

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Notice to Reviewer	Note to Reviewers CM-921 (Sep 2006).pdf	01/05/2007

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