OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act

ICR 201306-1240-002 · OMB 1240-0006 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CA-278 Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act Form and Instruction Modified Repair queued
dol-govt-1.doc Supplementary Document Uploaded 2013-06-13 Repair queued
SS 8147 Employees Compensation Fund.doc Supplementary Document Uploaded 2013-06-13 Repair queued
CFR-2010-title20-vol1-sec61-101.pdf Supplementary Document Uploaded 2013-06-13 Available
CFR-2010-title20-vol1-sec61-104.pdf Supplementary Document Uploaded 2013-06-13 Available
2012 Employment Wages for Insurance Claims and Policy Processing Clerks.doc Supplementary Document Uploaded 2013-06-13 Repair queued
2013 OPM Salary Table-Cleveland.pdf Supplementary Document Uploaded 2013-06-13 Repair queued
Supporting Stmt OMB 1240-0006.docx Supporting Statement A Uploaded 2013-10-21 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
13940 Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act Form and Instruction Modified
ICR Details
1240-0006 201306-1240-002
Historical Active 201005-1240-003
DOL/OWCP
Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act
Revision of a currently approved collection   No
Regular
Approved without change 12/27/2013
Retrieve Notice of Action (NOA) 10/29/2013
  Inventory as of this Action Requested Previously Approved
12/31/2016 36 Months From Approved 12/31/2013
393 0 269
197 0 135
1,407 0 557
Information collected using Form CA-278 will allow OWCP to consider requests filed by insurance carriers and self-insured that have paid benefits to workers injured due to a war-risk hazard to be reimbursed for such benefits out of the Employees' Compensation Fund.
US Code: 5 USC 8147 Name of Law: The Federal Employees' Compensation Act
   US Code: 42 USC 1701 Name of Law: War Hazards Compensation Act (WHCA)
  
None
Not associated with rulemaking
  78 FR 40514 07/05/2013
78 FR 64536 10/29/2013
No
  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 393 269 0 0 124 0
Annual Time Burden (Hours) 197 135 0 0 62 0
Annual Cost Burden (Dollars) 1,407 557 0 0 850 0
No
No
The previous approved number of annual respondents 269 is now 393, which represents an increase of 124. The previously approved number for burden hours was 135, and the requested number now is 197, an increase of $62.00. The costs burden for maintenance and reporting costs (postage and envelope) increased from $557 to $1,407, which is an adjustment of $850.00. Additionally, form was revised to include an accommodation statement to inform claimants who have mental or physical limitations to contact DFEC if further assistance is needed with the claims process.
$10,053
No
No
No
No
No
Uncollected
Marcus Sharpless 202 693-0998 [email protected]
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
10/29/2013