Information Collection

Health Insurance Claim Form

IC 43805 under ICR 202503-1240-003 · OMB 1240-0044.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OWCP-1500 Health Insurance Claim Form	Form and Instruction
Form OWCP-1500 Health Insurance Claim Form Health Insurance Claim Form	Form and Instruction
OWCP-1500 Health Insurance Claim Form 1240-0044 Health Insurance Claim Form (OWCP- 1500).pdf www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf	Form and Instruction
OWCP-1500 Health Insurance Claim Form 1240-0044 Health Insurance Claim Form (OWCP- 1500).pdf www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.801 20 CFR 725.704 20 CFR 725.405 20 CFR 725.715 20 CFR 30.701 20 CFR 725.701 20 CFR 725.406(e)

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 and Instruction	OWCP-1500			http://www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: DOL/GOVT-1(FECA); DOL/OWCP-2(BLBA); DOL/OWCP-11(EEOICPA)

FR Citation: 81 FR 25776

Number of Respondents: 43,706

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 67 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,544,050	3,544,050
Annual IC Time Burden (Hours)	413,473	413,473
Annual IC Cost Burden (Dollars)	0	0

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.

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