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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 703.2
20 CFR 703.209
20 CFR 702.210
20 CFR 703.203
20 CFR 703.303
20 CFR 703.205
20 CFR 703.204
20 CFR 703.212
20 CFR 703.304
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
LS-276
Application for Security Deposit Determination
LS-276.pdf
http://www.dol.gov/owcp/dlhwc/LS-276.pdf
Yes
No
Fillable Printable
Form
LS-275(IC)
Agreement and Undertaking (Insurance Carrier)
LS-275ic.pdf
http://www.dol.gov/owcp/dlhwc/LS-275ic.pdf
Yes
No
Fillable Printable
Form
LS-275(SI)
Agreement and Undertaking (Self-Insured Employer)
LS-275si.pdf
http://www.dol.gov/owcp/dlhwc/LS-275si.pdf
Yes
No
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 ESA-15
FR Citation:
67 FR 16886
Number of Respondents:
569
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
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
686
0
0
18
0
668
Annual IC Time Burden (Hours)
472
0
0
18
0
454
Annual IC Cost Burden (Dollars)
343
0
0
42
0
301
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.