Information Collection

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

IC 13940 under ICR 201306-1240-002 · OMB 1240-0006.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0006 can be found here:

Documents and Forms

Document Name Document Type
Form CA-278 Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act Form and Instruction
CA-278 Claim for Reimbursement of Benefit Payments and Claims E CA-278_revised.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	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 61.104 20 CFR 61.101

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-278	Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	CA-278_revised.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	No		Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: DOL/GOVT-1	FR Citation: 67 FR 16826

Number of Respondents: 7	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	393	124	269
Annual IC Time Burden (Hours)	197	62	135
Annual IC Cost Burden (Dollars)	1,407	850	557

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.