Notice of Issuance of Insurance Policy

Forms and Documents

Document Name	Status
Form CM-921 Notice of Issuance of Insurance Policy Form and Instruction	Modified
2013 Supporting Statement For CM-921 (1240-0048).docx Supporting Statement A	2013-05-23
20_CFR_Part_V_Subpart_C_726.208-213.pdf Supplementary Document	2013-05-10
30 USC Section 933.pdf Supplementary Document	2013-05-10
NCCI screen shot.docx Supplementary Document	2013-05-10

IC Document Collections

IC ID	Document Title	Status
13700	Notice of Issuance of Insurance Policy Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0048	ICR Reference No: 201303-1240-001
Status: Historical Active	Previous ICR Reference No: 201004-1240-008
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Notice of Issuance of Insurance Policy
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/09/2013
	Date Received in OIRA: 05/29/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2016	36 Months From Approved	07/31/2013
Responses	3,500	0	3,800
Time Burden (Hours)	8	0	633
Cost Burden (Dollars)	27	0	1,975

---

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.

---

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

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 15743	03/12/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 32276	05/29/2013
Did the Agency receive public comments on this ICR? No

---

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

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

---

ICR Summary 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	3,500	3,800	0	0	-300	0
Annual Time Burden (Hours)	8	633	0	-575	-50	0
Annual Cost Burden (Dollars)	27	1,975	0	-2,104	156	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: Yes

Burden Reduction Due to: Using Information Technology

Short Statement: The total number of burden hours and cost is reduced by 98.7% since the last clearance. Over 90 percent of the decrease is a result of the policy information from nearly all states being supplied to OWCP by NCCI by Secure FTP where State law requires workers' compensation insurance policy information to be reported to the State.

---

Annual Cost to Federal Government: $489

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]? No

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

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 05/29/2013

---