Notice of Issuance of Insurance Policy

ICR 201910-1240-005

OMB: 1240-0048

Federal Form Document

Forms and Documents
Document
Name
Status
Supporting Statement A
2020-07-29
Supplementary Document
2019-10-29
Supplementary Document
2013-05-10
Supplementary Document
2013-05-10
Supplementary Document
2013-05-10
IC Document Collections
IC ID
Document
Title
Status
13700
Modified
ICR Details
1240-0048 201910-1240-005
Active 201603-1240-002
DOL/OWCP
Notice of Issuance of Insurance Policy
Reinstatement without change of a previously approved collection   No
Regular
Approved with change 12/30/2020
Retrieve Notice of Action (NOA) 02/06/2020
  Inventory as of this Action Requested Previously Approved
12/31/2023 36 Months From Approved
3,465 0 0
61 0 0
9 0 0

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.

US Code: 30 USC 933 Section 423 Name of Law: The Black Lung Benefits Act
  
None

Not associated with rulemaking

  84 FR 61657 11/13/2019
85 FR 6978 02/06/2020
No

1
IC Title Form No. Form Name
Notice of Issuance of Insurance Policy

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 3,465 0 0 0 -35 3,500
Annual Time Burden (Hours) 61 0 0 0 3 58
Annual Cost Burden (Dollars) 9 0 0 0 9 0
No
No
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.

$2,795
No
    No
    No
No
No
No
No
Anjanette Suggs 202 354-9660 suggs.anjanette@dol.gov

  No

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.
02/06/2020


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