Carrier's Report of Issuance of Policy

Forms and Documents

Document Name	Status
Form LS-570 Carrier's Report of Issuance of Policy Form	Modified
1240-0004 - Justification for No materialNonsubstantive Change.docx Justification for No Material/Nonsubstantive Change	2020-12-15
Supporting Statement for 1240-0004 (LS-570) 2019.docx Supporting Statement A	2020-09-11

IC Document Collections

IC ID	Document Title	Status
190307	Carrier's Report of Issuance of Policy Form	Modified

ICR Details

OMB Control No: 1240-0004	ICR Reference No: 202008-1240-052
Status: Received in OIRA	Previous ICR Reference No: 201902-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Carrier's Report of Issuance of Policy
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 12/15/2020

	Requested	Previously Approved
Expiration Date	07/31/2022	07/31/2022
Responses	1,500	1,500
Time Burden (Hours)	25	25
Cost Burden (Dollars)	0	472

---

Abstract: The Carrier's Report of Issuance of Policy (Form LS-570) is used by authorized insurance carriers to report the policy of insurance issued for each insured employer. This form is to be sent to the Deputy Commissioner in the compensation district indicated by the employer's address. Section 32(a) of the LHWCA (33 USC 932(a)), requires every employer to secure the payment of such compensation with any insurance company authorized by the Secretary, to insure payment of compensation under this Act; or (2) receiving an authorization from the Secretary to pay such compensation directly.

---

Authorizing Statute(s): US Code: 33 USC 932(a) Name of Law: Longshore and Harbor Workers' Compensation Act
   US Code: 33 USC 939 Name of Law: Longshore and Harbor Workers' Compensation Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 67361	12/28/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 25074	05/31/2019
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Carrier's Report of Issuance of Policy	LS-570	Carrier's Report of Issuance of Policy

---

ICR Summary of Burden

	Total Request	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	1,500	1,500	0	0	0	0
Annual Time Burden (Hours)	25	25	0	0	0	0
Annual Cost Burden (Dollars)	0	472	0	-472	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $990

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 12/15/2020

---