Information Collection

Carrier's Report of Issuance of Policy

IC 190307 under ICR 201902-1240-003 · OMB 1240-0004.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0004 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form LS-570 Carrier's Report of Issuance of Policy	Form
LS-570 Carrier's Report of Issuance of Policy ls-570.pdf www.dol.gov/owcp/dlhwc/ls-570.pdf	Form

IC Title:

Carrier's Report of Issuance of Policy

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR CFR 703.116 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-570	Carrier's Report of Issuance of Policy	ls-570.pdf	https://www.dol.gov/owcp/dlhwc/ls-570.pdf	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: n/a

FR Citation: 67 FR 16886

Number of Respondents: 400

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,500	0	1,500
Annual IC Time Burden (Hours)	25	0	25
Annual IC Cost Burden (Dollars)	472	-308	780

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.