Information Collection

Notice of Issuance of Insurance Policy

IC 13700 under ICR 202401-1240-011 · OMB 1240-0048.

Documents and Forms

Document Name Document Type
Form CM-921 Notice of Issuance of Insurance Policy Form
Form CM-921 Notice of Issuance of Insurance Policy Form
CM-921 Instructions For Completion of Form CM-921 cm-921 Form.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-921 Instructions For Completion of Form CM-921 cm-921 Form.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Notice of Issuance of Insurance Policy	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 726.208 -.213 20 CFR 726.206

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-921	Instructions For Completion of Form CM-921	cm-921 Form.pdf	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,465	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,465	3,465
Annual IC Time Burden (Hours)	61	61
Annual IC Cost Burden (Dollars)	11	11

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.