Notice of Issuance of Insurance Policy

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CM-921 Notice of Issuance of Insurance Policy	Form and Instruction	Modified	Available
Justification 1240-0048 04-2010.doc	Supporting Statement A	Uploaded 2010-04-19	Available
30 USC 933.pdf	Supplementary Document	Uploaded 2007-01-10	Available
20 CFR Part V Subpart C 726.208-213.doc	Supplementary Document	Uploaded 2007-01-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13700	Notice of Issuance of Insurance Policy	Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0048	ICR Reference No: 201004-1240-008
Status: Historical Active	Previous ICR Reference No: 201003-1240-048
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Notice of Issuance of Insurance Policy
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/25/2010
	Date Received in OIRA: 04/23/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2013	36 Months From Approved	05/31/2010
Responses	3,800	0	4,000
Time Burden (Hours)	633	0	667
Cost Burden (Dollars)	1,975	0	1,880

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Abstract: The CM-921 provides insurance carriers with the means to supply DCMWC with information showing that a responsible coal mine operator is insured against liability for payment of compensation under the Federal Black Lung Benefits Act.

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Authorizing Statute(s): US Code: 30 USC 933 Section 423 Name of Law: The Black Lung Benefits Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 47275	09/15/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 21351	04/23/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Notice of Issuance of Insurance Policy	CM-921	Notice of Issuance of Insurance Policy

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,800	4,000	0	0	-200	0
Annual Time Burden (Hours)	633	667	0	0	-34	0
Annual Cost Burden (Dollars)	1,975	1,880	0	0	95	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The total number of burden hours is reduced by 5% since the last clearance. This adjustment is the result of a slight decline in coal mine operators and an increase in companies that are covered by self-insurance (Self-insured companies are not required to complete the CM-921). The slight increase in cost burden results from increased postage costs.

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Annual Cost to Federal Government: $8,097

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/23/2010

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