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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
1240-0048
ICR Reference No:
201910-1240-005
Status:
Historical Active
Previous ICR Reference No:
201603-1240-002
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Notice of Issuance of Insurance Policy
Type of Information Collection:
Reinstatement without change of a previously approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
12/30/2020
Retrieve Notice of Action (NOA)
Date Received in OIRA:
02/06/2020
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
12/31/2023
36 Months From Approved
Responses
3,465
0
0
Time Burden (Hours)
61
0
0
Cost Burden (Dollars)
9
0
0
Abstract:
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.
Authorizing Statute(s):
US Code:
30 USC 933 Section 423
Name of Law: The Black Lung Benefits 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:
84 FR 61657
11/13/2019
30-day Notice:
Federal Register Citation:
Citation Date:
85 FR 6978
02/06/2020
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
Notice of Issuance of Insurance Policy
ICR Summary of Burden
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
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:
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.
Annual Cost to Federal Government:
$2,795
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.
No
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.
No
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
Agency Contact:
Anjanette Suggs 202 354-9660 suggs.anjanette@dol.gov
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:
02/06/2020
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