Information Collection

Estimate/adjuster's Short Form Report/worksheet Contents/ Personl Property/statement Replacement Cost Coverage/proof Of Loss/notice Of Loss

IC 151799 under ICR 198201-3067-004 · OMB 3067-0021.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3067-0021 can be found here:

Documents and Forms

Document Name Document Type

No indexed documents/forms are available for this IC yet. A refresh has been queued.

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	ESTIMATE/ADJUSTER'S SHORT FORM REPORT/WORKSHEET CONTENTS/ PERSONL PROPERTY/STATEMENT REPLACEMENT COST COVERAGE/PROOF OF LOSS/NOTICE OF LOSS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	200,000	200,000
Annual IC Time Burden (Hours)	50,000	50,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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