Information Collection

Notice of Issuance of Insurance Policy

IC 13700 under ICR 201004-1240-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Notice of Issuance of Insurance Policy CM-921.pdf www.dol.gov/owcp/regs/compliance/cm-921.pdf	Form and Instruction

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	Notice of Issuance of Insurance Policy	CM-921.pdf	http://www.dol.gov/owcp/regs/compliance/cm-921.pdf	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

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	3,800	-200	4,000
Annual IC Time Burden (Hours)	633	-34	667
Annual IC Cost Burden (Dollars)	1,975	95	1,880

Documents for IC

table that charts IC Documents
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.