Notice of Issuance of Insurance Policy

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0048 can be found here:

Documents and Forms

Document Name Document Type
Form CM-921 Notice of Issuance of Insurance Policy Form
CM-921 Instructions For Completion of Form CM-921 Current CM-921.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-921 Instructions For Completion of Form CM-921 Current CM-921.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Notice of Issuance of Insurance Policy	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 726.206 20 CFR 726.208 -.213

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-921	Instructions For Completion of Form CM-921	Current CM-921.pdf	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,465	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,465	0	3,465
Annual IC Time Burden (Hours)	61	0	61
Annual IC Cost Burden (Dollars)	11	2	9

Documents for IC

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.