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Federal forms, ICRs, and supporting documents

Information Collection

Application for Self-Insurance Under the black Lung Benefits Act

IC 234819 under ICR 202404-1240-003 · OMB 1240-0057.

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Document Type
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Instruction
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Form
Information Collection (IC) Details

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Application for Self-Insurance Under the black Lung Benefits Act
 
No Modified
 
Mandatory
 
20 CFR 726.112 20 CFR 726.102

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CM-2017 Application or Renewal of Self-Insurance Authority CM-2017 Final 8.19.24.docx https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Yes Yes Fillable Printable
Instruction InstructionsforApplyingorRenewingSelf-Insurance 8.15.24.docx https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Yes Yes Fillable Printable
Form CM-2017b Report of Claims Information for Self-Insured Operators CM-2017b 8.15.24.docx https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Yes Yes Fillable Printable

Income Security General Retirement and Disability

DOL/OWCP-2  81 FR 25858

61 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 142 0 -176 24 0 294
Annual IC Time Burden (Hours) 246 0 -63 48 0 261
Annual IC Cost Burden (Dollars) 34,000 0 -80 0 0 34,080

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