Carrier's Report of Issuance of Policy

ICR 202201-1240-001

OMB: 1240-0004

Federal Form Document

Forms and Documents
IC Document Collections
190307 Modified
ICR Details
1240-0004 202201-1240-001
Received in OIRA 202008-1240-052
Carrier's Report of Issuance of Policy
Extension without change of a currently approved collection   No
Regular 06/10/2022
  Requested Previously Approved
36 Months From Approved 07/31/2022
1,500 1,500
25 25
15 0

The Carrier's Report of Issuance of Policy (Form LS-570) is used by authorized insurance carriers to report the policy of insurance issued for each insured employer. This form is to be sent to the Deputy Commissioner in the compensation district indicated by the employer's address. Section 32(a) of the LHWCA (33 USC 932(a)), requires every employer to secure the payment of such compensation with any insurance company authorized by the Secretary, to insure payment of compensation under this Act or receiving an authorization from the Secretary to pay such compensation directly.

US Code: 33 USC 932(a) Name of Law: Longshore and Harbor Workers' Compensation Act
   US Code: 33 USC 939 Name of Law: Longshore and Harbor Workers' Compensation Act

Not associated with rulemaking

  87 FR 3127 01/20/2022
87 FR 35573 06/10/2022

IC Title Form No. Form Name
Carrier's Report of Issuance of Policy LS-570 Carrier's Report of Issuance of Policy

  Total Request 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 1,500 1,500 0 0 0 0
Annual Time Burden (Hours) 25 25 0 0 0 0
Annual Cost Burden (Dollars) 15 0 0 0 15 0

Cheryl Jordan 202 693-0289 [email protected]


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:
    (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;
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.

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