Health Insurance Claim Form

Health Insurance Claim Form

OMB: 1240-0044

IC ID: 43805

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
Information Collection (IC) Details

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Health Insurance Claim Form
 
No Modified
 
Voluntary
 
20 CFR 10.801 20 CFR 725.704 20 CFR 30.701 20 CFR 725.701 20 CFR 725.406 20 CFR 725.405

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction OWCP-1500 Health Insurance Claim Form 1240-0044 Health Insurance Claim Form (OWCP-1500).pdf http://www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf Yes No Fillable Printable

Health Health Care Services

DOL/GOVT-1(FECA); DOL/OWCP-2(BLBA); DOL/OWCP-11(EEOICPA)   81 FR 47418

57,099 0
   
Private Sector Businesses or other for-profits
 
   22 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,381,232 0 0 0 0 3,381,232
Annual IC Time Burden (Hours) 321,455 0 0 0 0 321,455
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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