Information Collection

Application for Self-Insurance Under the black Lung Benefits Act

IC 234819 under ICR 202201-1240-003 · OMB 1240-0057.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0057 can be found here:

Documents and Forms

Document Name Document Type
Form CM-2017A Application for Self-Insurance Under the black Lung Benefits Act Form and Instruction
Instructions_for_Applying_or_Renewing_Self-insurance.for OCIO.1.15.19.pdf Instruction
CM-2017A Report of Claims Information cm-2017a.posted for public proposal.pdf Form and Instruction
CM-2017B Report of Claims Information cm-2017b.posted for public proposal.pdf Form and Instruction
CM-2017 Application or Renewal of Self-Insurance Authority cm-2017.for OCIO.1.15.19.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Self-Insurance Under the black Lung Benefits Act	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 726.102 20 CFR 726.112

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CM-2017A	Report of Claims Information	cm-2017a.posted for public proposal.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CM-2017B	Report of Claims Information	cm-2017b.posted for public proposal.pdf	Yes	Yes	Fillable Printable
Form	CM-2017	Application or Renewal of Self-Insurance Authority	cm-2017.for OCIO.1.15.19.pdf	Yes	Yes	Fillable Printable
Instruction			Instructions_for_Applying_or_Renewing_Self-insurance.for OCIO.1.15.19.pdf	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-2	FR Citation: 81 FR 25858

Number of Respondents: 49	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 33 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	294	-24	318
Annual IC Time Burden (Hours)	261	-22	283
Annual IC Cost Burden (Dollars)	34,080	33,935	145

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.