Information Collection

Notice of Issuance of Insurance Policy

IC 13700 under ICR 202306-1240-002 · OMB 1240-0048.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.