Notice of Issuance of Insurance Policy

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
SS 1240-0048 2016.docx	Supporting Statement A	Uploaded 2016-07-29	Available
20_CFR_Part_V_Subpart_C_726.208-213.pdf	Supplementary Document	Uploaded 2013-05-10	Available
30 USC Section 933.pdf	Supplementary Document	Uploaded 2013-05-10	Available
NCCI screen shot.docx	Supplementary Document	Uploaded 2013-05-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13700	Notice of Issuance of Insurance Policy		Modified

ICR Details

OMB Control No: 1240-0048	ICR Reference No: 201603-1240-002
Status: Historical Active	Previous ICR Reference No: 201303-1240-001
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: 11/21/2016
	Date Received in OIRA: 07/29/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2019	36 Months From Approved	11/30/2016
Responses	3,500	0	3,500
Time Burden (Hours)	58	0	8
Cost Burden (Dollars)	0	0	27

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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.

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

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 3477	01/21/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 50013	07/29/2016
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Notice of Issuance of Insurance Policy

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ICR Summary of Burden

table that charts list 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	3,500	0	0	0	0
Annual Time Burden (Hours)	58	8	0	0	50	0
Annual Cost Burden (Dollars)	0	27	0	0	-27	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: No

Burden Reduction Due to:

Short Statement: This information collection has been classified as a revision, because will discontinue use of Form CM–921 that a State previously has used to submit information directly to the DCMWC. A State now provides information to DCCI.

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Annual Cost to Federal Government: $579

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

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Common Form ICR:  No

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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: 07/29/2016

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