Carrier's Report of Issuance of Policy

OMB Control No: 1240-0004	ICR Reference No: 201003-1240-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Carrier's Report of Issuance of Policy
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/12/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/12/2010
Terms of Clearance: DOL is commended for finding and reporting this "bootleg" ICR. Please report accordingly in the appropriate ICB.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2012	36 Months From Approved
Responses	100,000	0	0
Time Burden (Hours)	8,333	0	0
Cost Burden (Dollars)	52,000	0	0

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Abstract: Form LS-570 is used by authorized insurance carriers to report the policy of insurance issued for each insured employer. This form is to be sent to the Deputy Commissioner in the compensation district indicated by the employer's address. Section 32 (a) of the LHWCA (33 USC 932(a)), requires every employer to secure the payment of such compensation with any insurance company authorized by the Secretary, to insure payment of compensation under this Act; or (2) receiving an authorization from the Secretary to pay such compensation directly.

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Authorizing Statute(s): US Code: 33 USC 932 (a) Name of Law: Longshore and Harbor Workers' Compensation Act

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 46619	09/10/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 59993	11/19/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title Form No. Form Name Carrier's Report of Issuance of Policy LS-570 Carrier's Report of Issuance of Policy

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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	100,000	0	0	0	0	100,000
Annual Time Burden (Hours)	8,333	0	0	0	0	8,333
Annual Cost Burden (Dollars)	52,000	0	0	0	0	52,000

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: New collection/form. Note to Reviewer: This procedure has been in place since the inception of the Act on March 4, 1927, predating the PRA. The carriers submitted the information directly to the District Offices using 2” X 5” cards. These cards have not been revised since the 1970s. Carriers have printed their own supplies, often electronically produced. The Division of Longshore and Harbor Workers' Compensation did not recognize that the Paper Work Reduction applied to this form. No changes were made to these regulations following the amendments to the Act in 1984, nor in the limited additional regulations relating to security promulgated in 2005. Recent Congressional interest in the Defense Base Act, an extension of the Longshore and Harbor Workers' Compensation Act, led to a commitment to Congress by the Deputy Secretary of Labor to automate the collection of this information. At this time the Division identified the need to remedy the lack of OMB clearance in the past and to create electronic systems which would allow the reception of data as part of the carriers’ normal reporting of workers’ compensation policies to the various states and eliminating duplicate reporting.

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Annual Cost to Federal Government: $168,577

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Cheryl Jordan 202 693-0289 [email protected]

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Common Form ICR:  No

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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: 11/19/2009

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