Application for Self-Insurance Under the black Lung Benefits Act

Application for Self-Insurance Under the Black Lung Benefits Act

OMB: 1240-0057

IC ID: 234819

Information Collection (IC) Details

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Application for Self-Insurance Under the black Lung Benefits Act
 
No Modified
 
Mandatory
 
20 CFR 726.102 20 CFR 726.112

Document Type Form No. Form Name Instrument File URL 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

Income Security General Retirement and Disability

DOL/OWCP-2  81 FR 25858

49 0
   
Private Sector Businesses or other for-profits
 
   33 %

  Requested 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 294 0 -24 0 0 318
Annual IC Time Burden (Hours) 261 0 -22 0 0 283
Annual IC Cost Burden (Dollars) 34,080 0 33,935 0 0 145

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.

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