OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Health Insurance Claim Form

OMB 1215-0055 ยท DOL/ESA.

OMB 1215-0055

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form OWCP-1500 Health Insurance Claim FormForm
83-I - Health Insurance Claim Form (1215-0055)(2009 clearance).doc Supplementary Document
Supporting Stmt for 1215-0055 (7 17 2009) final.docSupporting Statement A
20 CFR 725.405 BLBA Supporting Reg.(2009 clearance).doc Supplementary Document
20 CFR 30.701 EEOICPA Supporting Reg.(2009 clearance).doc Supplementary Document
20 CFR 10.801 FECA - Supporting Reg.(2009 clearance).doc Supplementary Document
Health Insurance Claim Form Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
200907-1215-001 Revision of a currently approved collection 2009-08-24 Approved without change
200610-1215-006 No material or nonsubstantive change to a currently approved collection 2006-10-31 Approved without change
200607-1215-001 Extension without change of a currently approved collection 2006-07-10 Approved without change
200506-1215-006 No material or nonsubstantive change to a currently approved collection 2005-06-29 Approved without change
200309-1215-002 Extension without change of a currently approved collection 2003-09-26 Approved without change
200108-1215-003 No material or nonsubstantive change to a currently approved collection 2001-08-03 Approved without change
200009-1215-001 Extension without change of a currently approved collection 2000-09-21 Approved without change
199709-1215-001 Extension without change of a currently approved collection 1997-09-24 Approved without change
199608-1215-007 No material or nonsubstantive change to a currently approved collection 1996-08-15 Approved without change
199409-1215-004 Revision of a currently approved collection 1994-09-01 Approved without change
199407-1215-004 No material or nonsubstantive change to a currently approved collection 1994-07-13 Approved with change
199307-1215-002 Revision of a currently approved collection 1993-07-22 Approved without change
199306-1215-006 No material or nonsubstantive change to a currently approved collection 1993-06-29 Approved with change
199111-1215-010 No material or nonsubstantive change to a currently approved collection 1991-11-19 Approved with change
199111-1215-007 Revision of a currently approved collection 1991-11-21 Approved without change
199103-1215-001 Revision of a currently approved collection 1991-03-14 Approved without change
199008-1215-001 Revision of a currently approved collection 1990-08-01 Approved without change
198710-1215-002 Revision of a currently approved collection 1987-10-19 Approved without change
198407-1215-012 Revision of a currently approved collection 1984-07-23 Approved without change
198309-1215-025 No material or nonsubstantive change to a currently approved collection 1983-09-06 Approved with change
198206-1215-001 Revision of a currently approved collection 1982-06-21 Approved without change
197808-1215-003 Revision of a currently approved collection 1978-08-17 Approved without change
197806-1215-004 Extension without change of a currently approved collection 1978-06-29 Approved without change