Information Collection

Health Insurance Claim Form

IC 43805 under ICR 201901-1240-004 · OMB 1240-0044.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0044 can be found here:

Documents and Forms

Document Name Document Type
Form OWCP-1500 Health Insurance Claim Form Form and Instruction
OWCP-1500 Health Insurance Claim Form OWCP-1500 Expires 5-31-2019.pdf www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf Form and Instruction
How To Submit OWCP 1500 Black Lung ICD10.pdf How to Submit OWCP 1500 Black Lung ICD10 IC Document
How To Submit OWCP 1500 Energy ICD10.pdf How To Submit OWCP 1500 Energy ICD10 IC Document
How To Submit OWCP-1500 FECA ICD10.pdf How To Submit OWCP-1500 FECA ICD10 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Insurance Claim Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 30.701 20 CFR 725.701 20 CFR 10.801 20 CFR 725.704 20 CFR 725.406 20 CFR 725.405

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-1500	Health Insurance Claim Form	OWCP-1500 Expires 5-31-2019.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/GOVT-1(FECA); DOL/OWCP-2(BLBA); DOL/OWCP-11(EEOICPA)	FR Citation: 81 FR 25766

Number of Respondents: 57,099	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 22 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,381,232	3,381,232
Annual IC Time Burden (Hours)	321,455	321,455
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
How to Submit OWCP 1500 Black Lung ICD10	How To Submit OWCP 1500 Black Lung ICD10.pdf	08/20/2015
How To Submit OWCP 1500 Energy ICD10	How To Submit OWCP 1500 Energy ICD10.pdf	08/20/2015
How To Submit OWCP-1500 FECA ICD10	How To Submit OWCP-1500 FECA ICD10.pdf	08/20/2015

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