Carrier's Report of Issuance of Policy

ICR 201506-1240-003

OMB: 1240-0004

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Justification for No Material/Nonsubstantive Change
2014-12-18
Supporting Statement A
2012-11-01
IC Document Collections
IC ID
Document
Title
Status
190307 Modified
ICR Details
1240-0004 201506-1240-003
Historical Active 201209-1240-003
DOL/OWCP
Carrier's Report of Issuance of Policy
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 06/05/2015
Retrieve Notice of Action (NOA) 06/05/2015
  Inventory as of this Action Requested Previously Approved
01/31/2016 01/31/2016 01/31/2016
5,000 0 5,000
83 0 83
2,088 0 2,650

The Carrier's Report of Issuance of Policy (Form LS-570) is used by authorized insurance carriers to report the policy of insurance issued for each insured employer. This form is to be sent to the Deputy Commissioner in the compensation district indicated by the employer's address. Section 32(a) of the LHWCA (33 USC 932(a)), requires every employer to secure the payment of such compensation with any insurance company authorized by the Secretary, to insure payment of compensation under this Act; or (2) receiving an authorization from the Secretary to pay such compensation directly.

US Code: 33 USC 932(a) Name of Law: Longshore and Harbor Workers' Compensation Act
  
None

Final or interim final rulemaking 80 FR 12917 03/12/2015

  77 FR 52370 08/29/2012
77 FR 73682 12/11/2012
No

1
IC Title Form No. Form Name
Carrier's Report of Issuance of Policy LS-570 Carrier's Report of Issuance of Policy

  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 5,000 5,000 0 0 0 0
Annual Time Burden (Hours) 83 83 0 0 0 0
Annual Cost Burden (Dollars) 2,088 2,650 0 -562 0 0
No
No

$3,090
No
No
No
No
No
Uncollected
Cheryl Jordan 202 693-0289 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
03/12/2015


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