Notice of Issuance of Insurance Policy

Forms and Documents

Document Name	Status
Form CM-921 Notice of Issuance of Insurance Policy Form	Modified
2023 30-Day FRN_1240-0048.pdf Supplementary Document	2023-10-04
2023 60-Day FRN_1240-0048.pdf Supplementary Document	2023-09-28
SS 1240-0048 9.11.23_MN-MM.docx Supporting Statement A	2023-09-28
System of Record Notice-DOL OWCP-2.pdf Supplementary Document	2019-10-29
20_CFR_Part_V_Subpart_C_726.208-213.pdf Supplementary Document	2013-05-10
30 USC Section 933.pdf Supplementary Document	2013-05-10
NCCI screen shot.docx Supplementary Document	2013-05-10

IC Document Collections

IC ID	Document Title	Status
13700	Notice of Issuance of Insurance Policy Form	Modified

ICR Details

OMB Control No: 1240-0048	ICR Reference No: 202306-1240-002
Status: Received in OIRA	Previous ICR Reference No: 201910-1240-005
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Notice of Issuance of Insurance Policy
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/04/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2023
Responses	3,465	3,465
Time Burden (Hours)	61	61
Cost Burden (Dollars)	11	9

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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:
	88 FR 44157	07/11/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 68674	10/04/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Notice of Issuance of Insurance Policy	CM-921	Instructions For Completion of Form CM-921

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ICR Summary of Burden

	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	3,465	3,465	0	0	0	0
Annual Time Burden (Hours)	61	61	0	0	0	0
Annual Cost Burden (Dollars)	11	9	0	2	0	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:

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Annual Cost to Federal Government: $3,099

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: 10/04/2023

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