Application for Self-Insurance Under the black Lung Benefits Act

Application for Self-Insurance Under the Black Lung Benefits Act

OMB: 1240-0057

IC ID: 234819

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Form
Form
Form
Form
Form
Form
Information Collection (IC) Details

View Information Collection (IC)

Application for Self-Insurance Under the black Lung Benefits Act
 
No Modified
 
Mandatory
 
20 CFR 726.102 20 CFR 726.112

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Instructions_for_Applying_or_Renewing_Self-insurance.for OCIO.1.15.19.pdf Yes Yes Fillable Printable
Form CM-2017 Application or Renewal of Self-Insurance Authority cm-2017 Form.pdf https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Yes Yes Fillable Printable
Form CM-2970a Financial Summary for Self-Insured Operators cm-2017a Form.pdf https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Yes Yes Fillable Printable
Form CM-2017b Report of Claims Information for Self-Insured Operators cm-2017b.pdf https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Yes Yes Fillable Printable

Income Security General Retirement and Disability

DOL/OWCP-2  81 FR 25858

49 0
   
Private Sector Businesses or other for-profits
 
   33 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 294 0 0 0 0 294
Annual IC Time Burden (Hours) 261 0 0 0 0 261
Annual IC Cost Burden (Dollars) 34,080 0 0 0 0 34,080

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