Notice of Issuance of Insurance Policy

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
20200720 CM 921 SS 1240-0048.docx	Supporting Statement A	Uploaded 2020-07-29	Available
System of Record Notice-DOL OWCP-2.pdf	Supplementary Document	Uploaded 2019-10-29	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	Repair queued
NCCI screen shot.docx	Supplementary Document	Uploaded 2013-05-10	Repair queued

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: 201910-1240-005
Status: Active	Previous ICR Reference No: 201603-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Notice of Issuance of Insurance Policy
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/30/2020
	Date Received in OIRA: 02/06/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2023	36 Months From Approved
Responses	3,465	0	0
Time Burden (Hours)	61	0	0
Cost Burden (Dollars)	9	0	0

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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:
	84 FR 61657	11/13/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 6978	02/06/2020
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	3,465	0	0	0	-35	3,500
Annual Time Burden (Hours)	61	0	0	0	3	58
Annual Cost Burden (Dollars)	9	0	0	0	9	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: The estimated annual burden increased by three hours due entirely to a revised burden estimate that now includes CM-921 filings from either state agencies or insurance carriers that cannot use the NCCI/OWCP MOU to submit via a secure FTP server. There has been an adjustment to the annualized cost to the Federal government due to increased use of the NCCI data. Claims examiners access NCCI for insurance coverage matters and also query for tax ID numbers, subsidiary lists, and addresses. Minor changes have been made to the Instructions for the CM-921 to update antiquated language, add an electronic filing option, and request the MSHA ID.

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Annual Cost to Federal Government: $2,795

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? No

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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: 02/06/2020

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