Information Collection

Application for Self-Insurance Under the Black Lung Benefits Act

IC 234819 under ICR 202301-1240-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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-2017b Application for Self-Insurance Under the Black Lung Benefits Act Form
InstructionsforApplyingorRenewingSelf-Insurance 1.10.23.docx www.dol.gov/sites/dolgov/files/owcp/regs/compliance/cm-2017.pdf Instruction
InstructionsforApplyingorRenewingSelf-Insurance 1.10.23.docx www.dol.gov/sites/dolgov/files/owcp/regs/compliance/cm-2017.pdf Instruction
CM-2017b Report of Claims Information for Self-Insured Operators cm-2017b NPRM.docx www.dol.gov/sites/dolgov/files/owcp/regs/compliance/cm-2017b.pdf Form
CM-2017b Report of Claims Information for Self-Insured Operators cm-2017b NPRM.docx www.dol.gov/sites/dolgov/files/owcp/regs/compliance/cm-2017b.pdf Form
CM-2017 Application or Renewal of Self-Insurance Authority cm-2017 Application. NPRM.docx www.dol.gov/sites/dolgov/files/owcp/regs/compliance/cm-2017.pdf Form
CM-2017 Application or Renewal of Self-Insurance Authority cm-2017 Application. NPRM.docx www.dol.gov/sites/dolgov/files/owcp/regs/compliance/cm-2017.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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-2017b	Report of Claims Information for Self-Insured Operators	cm-2017b NPRM.docx	https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/cm-2017b.pdf	Yes	Yes	Fillable Fileable Signable
Form	CM-2017	Application or Renewal of Self-Insurance Authority	cm-2017 Application. NPRM.docx	https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/cm-2017.pdf	Yes	Yes	Fillable Fileable Signable
Instruction			InstructionsforApplyingorRenewingSelf-Insurance 1.10.23.docx	https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/cm-2017.pdf	Yes	No	Printable Only

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: 61	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	122	-172	294
Annual IC Time Burden (Hours)	244	-17	261
Annual IC Cost Burden (Dollars)	34,000	-80	34,080

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.