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

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

OMB: 1240-0005

IC ID: 13942

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 703.203 20 CFR 703.209 20 CFR 702.210 20 CFR 703.303 20 CFR 703.205 20 CFR 703.204 20 CFR 703.212 20 CFR 703.304 20 CFR 703.2

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form LS-276 Application for Security Deposit Determination ls-265.pdf http://www.dol.gov/owcp/dlhwc/LS-276.pdf Yes No Fillable Printable
Form LS-275(IC) Agreement and Undertaking (Insurance Carrier) LS-275ic.pdf http://www.dol.gov/owcp/dlhwc/LS-275ic.pdf Yes No Fillable Printable
Form LS-275(SI) Agreement and Undertaking (Self-Insured Employer) LS-275si.pdf http://www.dol.gov/owcp/dlhwc/LS-275si.pdf Yes No Fillable Printable

Income Security General Retirement and Disability

DOL ESA-15  67 FR 16870

469 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 651 0 79 -74 0 646
Annual IC Time Burden (Hours) 437 0 0 3 0 434
Annual IC Cost Burden (Dollars) 322 0 152 -118 0 288

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