View Information Collection (IC)

View Information Collection (IC)

IC Title:	Notice of Issuance of Insurance Policy	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 726.208 -.213 20 CFR 726.206

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CM-921	Instructions for Completion of Form CM-921	CM-921 form and instructions.pdf	http://www.dol.gov/esa/regs/compliance/owcp/cm-921.pdf	Yes	No	Fillable Printable
Form and Instruction	CM-921	Instructions for Completion of Form CM-921	CM-921 form and Instructions draft 9-20-06.pdf	http://www.dol.gov/esa/regs/compliance/owcp/cm-921.pdf	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: DOL/ESA-6	FR Citation: 67 FR 16869

Number of Respondents: 4,000	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	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	4,000	0	0	0	0	4,000
Annual IC Time Burden (Hours)	667	0	0	0	0	667
Annual IC Cost Burden (Dollars)	1,880	0	0	-120	0	2,000

Documents for IC

Title	Document	Date Uploaded
Notice to Reviewer	Note to Reviewers CM-921 (Sep 2006).pdf	01/05/2007

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