Information Collection

Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions

IC 13942 under ICR 202304-1240-005 · OMB 1240-0005.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form LS-276 Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions	Form and Instruction
LS-276 Application for Security Deposit Determination LS-276.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-276.pdf	Form and Instruction
LS-276 Application for Security Deposit Determination LS-276.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-276.pdf	Form and Instruction
LS-275 (SI) Agreement and Undertaking (Self-Insured Employer) LS-275si - 6-13-23.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-275si.pdf	Form
LS-275 (SI) Agreement and Undertaking (Self-Insured Employer) LS-275si - 6-13-23.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-275si.pdf	Form
LS-275 (IC) Agreement and Undertaking (Insurance Carrier) LS-275ic 6-13-2023.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-275ic.pdf	Form
LS-275 (IC) Agreement and Undertaking (Insurance Carrier) LS-275ic 6-13-2023.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-275ic.pdf	Form

IC Title:

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 703.209 20 CFR 703.205 20 CFR 703.204 20 CFR 703.203 20 CFR 702.210 20 CFR 703.303 20 CFR 703.212 20 CFR 703.304

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 and Instruction	LS-276	Application for Security Deposit Determination	LS-276.pdf	https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-276.pdf	Yes	No	Fillable Printable
Form	LS-275 (SI)	Agreement and Undertaking (Self-Insured Employer)	LS-275si - 6-13-23.pdf	https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-275si.pdf	Yes	Yes	Fillable Fileable Signable
Form	LS-275 (IC)	Agreement and Undertaking (Insurance Carrier)	LS-275ic 6-13-2023.pdf	https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-275ic.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/OWCP-3, DOL/OWCP-4

FR Citation: 88 FR 8321

Number of Respondents: 705

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	705	10	695
Annual IC Time Burden (Hours)	881	12	869
Annual IC Cost Burden (Dollars)	409	397	12

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.