Notice of Issuance of Insurance Policy

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0048 can be found here:

Documents and Forms

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 Word Version new.pdf www.dol.gov/owcp/regs/compliance/cm-921.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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:

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 Word Version new.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: 51	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 99 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,500	0	-300	3,800
Annual IC Time Burden (Hours)	8	-575	-50	633
Annual IC Cost Burden (Dollars)	27	-2,104	156	1,975

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.