View Information Collection (IC)

View Information Collection (IC)

IC Title:	Application for Self-Insurance Under the black Lung Benefits Act	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 726.102 20 CFR 726.112

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CM-2017A	Report of Claims Information	cm-2017a.posted for public proposal.pdf		Yes	Yes	Fillable Printable
Form and Instruction	CM-2017B	Report of Claims Information	cm-2017b.posted for public proposal.pdf		Yes	Yes	Fillable Printable
Form	CM-2017	Application or Renewal of Self-Insurance Authority	cm-2017.for OCIO.1.15.19.pdf		Yes	Yes	Fillable Printable
Instruction			Instructions_for_Applying_or_Renewing_Self-insurance.for OCIO.1.15.19.pdf		Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-2	FR Citation: 81 FR 25858

Number of Respondents: 53	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 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	318	0	318	0	0	0
Annual IC Time Burden (Hours)	283	0	283	0	0	0
Annual IC Cost Burden (Dollars)	145	0	145	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.