OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Notice of Issuance of Insurance Policy

OMB 1240-0048 ยท DOL/OWCP.

OMB 1240-0048

The CM-921 provides insurance carriers with the means to supply DCMWC with information showing that a responsible coal mine operator is insured against liability for payment of compensation under the Federal Black Lung Benefits Act.

The latest form for Notice of Issuance of Insurance Policy expires 2026-11-30 and is listed under ICR 202401-1240-011.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CM-921 Notice of Issuance of Insurance PolicyForm
Form CM-921 Notice of Issuance of Insurance PolicyForm
SS 1240-0048 9.11.23_MN-MM.docxSupporting Statement A
SS 1240-0048 9.11.23_MN-MM.docxSupporting Statement A
Justification CM-921.docx Justification for No Material/Nonsubstantive Change
2023 30-Day FRN_1240-0048.pdf Supplementary Document
2023 30-Day FRN_1240-0048.pdf Supplementary Document
2023 60-Day FRN_1240-0048.pdf Supplementary Document
2023 60-Day FRN_1240-0048.pdf Supplementary Document
System of Record Notice-DOL OWCP-2.pdf Supplementary Document
System of Record Notice-DOL OWCP-2.pdf Supplementary Document
20_CFR_Part_V_Subpart_C_726.208-213.pdf Supplementary Document
20_CFR_Part_V_Subpart_C_726.208-213.pdf Supplementary Document
30 USC Section 933.pdf Supplementary Document
30 USC Section 933.pdf Supplementary Document
NCCI screen shot.docx Supplementary Document
NCCI screen shot.docx Supplementary Document
Notice of Issuance of Insurance Policy Form
Notice of Issuance of Insurance Policy Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202401-1240-011 No material or nonsubstantive change to a currently approved collection 2024-01-31 Approved without change
202306-1240-002 Revision of a currently approved collection 2023-10-04 Approved without change
201910-1240-005 Reinstatement without change of a previously approved collection 2020-02-06 Approved with change
201603-1240-002 Revision of a currently approved collection 2016-07-29 Approved without change
201303-1240-001 Revision of a currently approved collection 2013-05-29 Approved without change
201004-1240-008 Extension without change of a currently approved collection 2010-04-23 Approved without change
201003-1240-048 Extension without change of a currently approved collection 2007-01-19 Approved without change