Information Collection

Health Insurance Claim Form

IC 43805 under ICR 202102-1240-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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.pdf www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf Form and Instruction
OWCP-1500 Health Insurance Claim Form owcp-1500.pdf www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf Form and Instruction

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: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 725.701 20 CFR 725.406(e) 20 CFR 10.801 20 CFR 725.704 20 CFR 725.405 20 CFR 725.715 20 CFR 30.701

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.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 25776

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,381,232	0	3,381,232
Annual IC Time Burden (Hours)	394,477	73,022	321,455
Annual IC Cost Burden (Dollars)	0	0	0

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.