Ss 1240-0048 9.11.23_mn-mm

Notice of Issuance of Insurance Policy

OMB Control Number 1240-0048

OMB Expiration Date: 12/31/2023

SUPPORTING STATEMENT FOR

Notice of Issuance of Insurance Policy

OMB CONTROL NO. 1240-0048

This ICR seeks to revise the currently approved version.

1. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

The Black Lung Benefits Act (the Act), 30 U.S.C. 901-944, requires coal mine operators to be insured (either by qualifying as a self-insurer or obtaining commercial insurance) for liabilities arising from the Act; failure to do so may result in civil money penalties. 30 U.S.C. 933 (http://www.gpo.gov/fdsys/pkg/USCODE-2011-title30/html/USCODE-2011-title30-chap22-subchapIV-partC-sec933.htm). Accordingly, 20 CFR Part V, Subpart C, 726.208 - .213 (http://www.ecfr.gov/cgi-bin/text-idx?SID=6879d5bc7d2580bacd2c5531e3c57c15&mc=true&node=sg20.4.726_1207.sg0&rgn=div7) requires insurance carriers to report to the Division of Coal Mine Workers’ Compensation (DCMWC) each policy and endorsement issued, cancelled, or renewed with respect to operators in such a manner and on such form as DCMWC may require. These regulations also require carriers to file a separate report for each operator it insures. Carriers use Form CM-921, Notice of Issuance of Insurance Policy, to report issuance of insurance policies to operators.

When the insured coal mining operations are conducted in a State that reports all workers’ compensation to the National Council on Compensation Insurance (NCCI), DCMWC does not require the carrier to file Form CM-921. OWCP and NCCI have a Memorandum of Understanding (MOU) in place that permits NCCI to provide policy information directly to OWCP via Secure FTP (File Transfer Protocol) server. However, carriers writing coverage outside of NCCI-reporting states must file Form CM-921.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

The CM-921 will be completed by the insurance carrier and forwarded to the Department for review when not reporting to NCCI. DCMWC staff reviews any completed CM-921 to identify those operators who have secured insurance for payment of black lung benefits as required by Section 423 of the Act.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology (e.g., permitting electronic submission of responses) and the basis for the decision to adopt this means of collection. Also, describe any consideration of using information technology to reduce burden.

In accordance with the Government Paperwork Elimination Act (GPEA), DCMWC recognizes the requirement that all OMB forms be made electronically interactive. The Office of Workers’ Compensation Programs (OWCP) has developed a method for electronic submission of the CM-921. The form is available online at http://www.dol.gov/owcp/regs/compliance/cm-921.pdf. The form can be completed online, printed, signed and e-mailed to [email protected], or the form can be completed online, printed, signed, and mailed to: U.S. Department of Labor, Office of Workers’ Compensation Program, Division of Coal Mine Workers’ Compensation, 200 Constitution Avenue, NW Suite C3520-DCMWC Washington, DC 20210.

Respondents who report all operator coverage to NCCI do not need to file this form. OWCP and NCCI have a Memorandum of Understanding in place that permits NCCI to provide policy information directly to OWCP via Secure FTP (File Transfer Protocol) server. Any other respondents in states that do not have such capability must submit the actual form to DCMWC.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item A.2 above.

There is no similar approved information collection form used by DCMWC or the Federal government for insurance carriers to report coverage of coal mine operators under the Act. Many states also collect this information through NCCI. OWCP and NCCI have a Memorandum of Understanding in place that permits NCCI to provide policy information directly to OWCP via Secure FTP (File Transfer Protocol) server; therefore, OWCP has removed reporting that is duplicative with state requirements.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

This information collection does not have a significant economic impact on a substantial number of small entities.

6. Describe the consequence to federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

This information is collected each time a carrier issues or renews a policy to an operator to cover liabilities under the Act. DCMWC needs to collect this information to ensure operators are complying with their statutory insurance obligations and to identify liable parties when a claim for benefits is filed.

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary, trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

There are no special circumstances for conducting this information collection.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.

Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years -- even if the collection-of-information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

A Federal Register Notice inviting public comment was published on 07/11/2023 (88 FR 44157). No comments were received.

OWCP has not consulted with the public for this specific ICR during the last 3-year period. We are in the process of reviewing all our ICR requirements and implementing procedures to comply with M-22-10 for any ICR’s submitted to OMB after Oct.1 2023 and will continue thereafter.

9. Explain any decision to provide any payments or gifts to respondents, other than remuneration of contractors or grantees.

No payments or gifts are provided to respondent.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

No assurance of confidentiality is provided. No information covered by the Privacy Act of 1974 is collected.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

This collection contains no questions of a sensitive nature.

12. Provide estimates of the hour burden of the collection of information. The statement should:

• Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.¹

• If this request for approval covers more than one form, provide separate hour burden estimates for each form.

• Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 13.

Estimated Annualized Respondent Cost and Hour Burden

Activity	No. of Respondents	No. of Responses per Respondent	Total Responses	Average Burden (Hours)	Total Burden (Hours)	Hourly Wage Rate	Monetized Value of Respondent Time
CM-921 (NCCI Carriers)	3,450	1	3,450	0.0167 (1 min.)	58	$21.90	$1,270.2
CM-921 (non-NCCI Carriers)	15	1	15	0.1667 (10 min.)	3	$21.90	$65.70
Unduplicated	3,465		3,465		61	$21.90	$1,336 Rounded up

The public burden estimate of this information collection is approximately 61 (58 + 3) hours for reports sent to NCCI. This burden is based on NCCI receiving 3,450 electronic responses, one response annually from each respondent. It is estimated that it takes each respondent one (1) minute to confirm their coverage electronically with NCCI.

3,450 responses X 1 minute = 3,450 minutes

3,450 x 0.0167=58 (57.61 rounded up to 58)

Another public burden estimate of this information collection is approximately 3 hours for the CM-921 forms filed with DCMWC by other carriers. This burden is based on approximately 10 minutes for retrieving the information and completing each of the around 15 forms received each year. There are some state agencies or insurance carriers insuring approximately 15 coal mine operators that cannot use the NCCI/OWCP MOU to provide coverage information by Secure FTP.

15 forms X 10 minutes = 150/60 = 3 hours (2.505 rounded up)

Total number of responses is 3,465 (3,450 + 15).

The estimated annualized cost to respondents to provide this information is $1,336.00 This was determined by using the weekly wage of the Office and Administrative Support Positions ($21.90 per hour average) of the Usual Weekly Earning of Wage and Salary Workers 2022, published by the Bureau of Labor Statistics https://www.bls.gov/oes/current/oes430000.htm

61 hours X $21.90 per hour = $1,336.00 ($1,335.90 rounded up)

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

• The cost estimate should be split into two components: (a) a total capital

and start up cost component (annualized over its expected useful life); and (b) a

total operation, maintenance and purchase of service component.

The estimates should take into account costs associated with generating,

maintaining, and disclosing or providing the information. Include descriptions of

methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

• If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.

• Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government or (4) as part of customary and usual business or private practices.

Operation and maintenance costs to print and mail the form is $11.00. This estimate is based on a cost of $0.66 per stamp, $0.03 per envelope, and .05 per form, for a per-form cost of $0.74 for each of the 15 forms mailed. OWCP does not believe insurance companies reporting coverage through NCCI will incur any additional operation and maintenance costs.

15 forms X $0.74 = $11.00 ($11.10 rounded down)

14. Provide estimates of the annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 into a single table.

The estimated total annual cost to the Federal government is approximately $3,099 ($2,659 + $44.45 + $396).

Claims examiners view available information from NCCI approximately 4,000 times annually. Each view performed by a claim’s examiner (GS-12/1) will take approximately one minute to perform. The hourly rate of a GS-12/1 claims examiner is $39.69 https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2023/RUS_h.pdf

The annualized cost to the Federal government is figured as follows:

4,000 x 0.0167= 67 hours (66.8 Rounded up) X $39.69 per hour = $2,659 ($2,659.23 rounded down)

Fifteen of the forms received by DCMWC are reviewed by one data entry clerk (GS-5/8) earning $22.28 per hour (https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2023/RUS_h.pdf) spending about 8 minutes (0.1333 hour) reviewing the form, entering the data into the computer system, and filing the form.

15 forms X 0.133 = 1.995 hours

1.995 X $22.28 = $44.45

OWCP estimates the Agency spends $396 per year to maintain its side of the FTP with NCCI.

15. Explain the reasons for any program changes or adjustments.

EXPLANATION OF CHANGE TOTALS

Respondents: The number of respondents remained at 3,465.

Responses: The number of responses remained at 3,465.

Burden Hours: Total burden hours remained at 61.

Costs: Annual burden costs have increased from $9.00 to $11.00 due to an increase of postage.

16. For collections of information whose results will be published, outline plans for tabulations, and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

There are no plans to publish this collection of information.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

This ICR does not seek a waiver from the requirement to display the expiration date.

18. Explain each exception to the certification statement.

There are no exceptions to the certification statement.

B. COLLECTIONS OF INFORMATON EMPLOYING STATISTICAL METHODS.

Statistical methods are not used in these collections of information.

1 Indicate the retention period for any recordkeeping requirements that pertain to the ICR.

9