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 estimated annual burden
increased by three hours due entirely to a revised burden estimate
that now includes CM-921 filings from either state agencies or
insurance carriers that cannot use the NCCI/OWCP MOU to submit via
a secure FTP server. There has been an adjustment to the annualized
cost to the Federal government due to increased use of the NCCI
data. Claims examiners access NCCI for insurance coverage matters
and also query for tax ID numbers, subsidiary lists, and addresses.
Minor changes have been made to the Instructions for the CM-921 to
update antiquated language, add an electronic filing option, and
request the MSHA ID.
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.