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⚠️ Notice: This information collection may be referencing outdated material.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 and Instruction
OWCP-1500 Health Insurance Claim Form owcp-1500_new.pdf www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf 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 725.701 20 CFR 10.801 20 CFR 725.704 20 CFR 30.701 20 CFR 725.405

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-1500	Health Insurance Claim Form	owcp-1500_new.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf	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: 71,304	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	3,036,067	39,651	2,996,416
Annual IC Time Burden (Hours)	322,838	-36,521	359,359
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.