Information Collection Request
Health Insurance Claim Form
ICR 202312-1240-004 · OMB 1240-0044 · Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0044 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form OWCP-1500 Health Insurance Claim Form |
Form and Instruction | Modified | Available |
| Form OWCP-1500 Health Insurance Claim Form |
Form and Instruction | Modified | Missing upstream |
 Justification-1240-0044 Health Insurance Claim Form (OWCP-1500).docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2023-12-26 | Available |
| Justification-1240-0044 Health Insurance Claim Form (OWCP-1500).docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2023-12-26 | Repair queued |
 1240-0044 Health Insurance Claim Form (OWCP-1500) Highlighted Changes.pdf |
Supplementary Document | Uploaded 2023-12-26 | Available |
| 1240-0044 Health Insurance Claim Form (OWCP-1500) Highlighted Changes.pdf |
Supplementary Document | Uploaded 2023-12-26 | Repair queued |
| 30-day FRN (1240-0044) published.pdf |
Supplementary Document | Uploaded 2021-05-03 | Available |
| 30-day FRN (1240-0044) published.pdf |
Supplementary Document | Uploaded 2021-05-03 | Repair queued |
| 60-day FRN (1240-0044) published.pdf |
Supplementary Document | Uploaded 2021-04-30 | Available |
| 60-day FRN (1240-0044) published.pdf |
Supplementary Document | Uploaded 2021-04-30 | Repair queued |
| 1240-0044 Supporting Statement (Final).docx |
Supporting Statement A | Uploaded 2021-04-23 | Available |
| 1240-0044 Supporting Statement (Final).docx |
Supporting Statement A | Uploaded 2021-04-23 | Repair queued |
| Privacy Act System of Records - FEC.docx |
Supplementary Document | Uploaded 2020-09-09 | Available |
| Privacy Act System of Records - FEC.docx |
Supplementary Document | Uploaded 2020-09-09 | Repair queued |
 20 CFR 725.405 BLBA Supporting Reg.doc |
Supplementary Document | Uploaded 2012-10-23 | Available |
| 20 CFR 725.405 BLBA Supporting Reg.doc |
Supplementary Document | Uploaded 2012-10-23 | Repair queued |
| 20 CFR 30.701 EEOICPA Supporting Reg.doc |
Supplementary Document | Uploaded 2012-10-23 | Repair queued |
| 20 CFR 30.701 EEOICPA Supporting Reg.doc |
Supplementary Document | Uploaded 2012-10-23 | Repair queued |
| 20 CFR 10.801 FECA - Supporting Reg.doc |
Supplementary Document | Uploaded 2012-10-23 | Available |
| 20 CFR 10.801 FECA - Supporting Reg.doc |
Supplementary Document | Uploaded 2012-10-23 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 43805 |  Health Insurance Claim Form |
Form and Instruction | Modified | |
| 43805 | Health Insurance Claim Form |
Form and Instruction | Modified |
ICR Details
| Status | Active |
|---|---|
| Agency/Subagency | DOL/OWCP |
| OMB Control No | 1240-0044 |
| Type of Information Collection | No material or nonsubstantive change to a currently approved collection |
| Previous ICR Reference No | 202102-1240-003 |
| Date Submitted to OIRA | 2023-12-27 |
| Requested Expiration Date | 1969-12-31 |