Information Collection

Application for Self-Insurance Under the black Lung Benefits Act

IC 234819 under ICR 201901-1240-008 · OMB 1240-0057.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0057 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-2017A Application for Self-Insurance Under the black Lung Benefits Act	Form and Instruction
Instructions_for_Applying_or_Renewing_Self-insurance.for OCIO.1.15.19.pdf	Instruction
CM-2017A Report of Claims Information cm-2017a.posted for public proposal.pdf	Form and Instruction
CM-2017B Report of Claims Information cm-2017b.posted for public proposal.pdf	Form and Instruction
CM-2017 Application or Renewal of Self-Insurance Authority cm-2017.for OCIO.1.15.19.pdf	Form

IC Title:

Application for Self-Insurance Under the black Lung Benefits Act

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 726.102 20 CFR 726.112

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CM-2017A	Report of Claims Information	cm-2017a.posted for public proposal.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CM-2017B	Report of Claims Information	cm-2017b.posted for public proposal.pdf	Yes	Yes	Fillable Printable
Form	CM-2017	Application or Renewal of Self-Insurance Authority	cm-2017.for OCIO.1.15.19.pdf	Yes	Yes	Fillable Printable
Instruction			Instructions_for_Applying_or_Renewing_Self-insurance.for OCIO.1.15.19.pdf	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/OWCP-2

FR Citation: 81 FR 25858

Number of Respondents: 53

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 33 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	318	318
Annual IC Time Burden (Hours)	283	283
Annual IC Cost Burden (Dollars)	145	145

Documents for IC

table that charts IC Documents
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.