Information Collection Request
Health Insurance Claim Form
ICR 202404-1240-009 · OMB 1240-0044 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0044 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form OWCP-1500 Health Insurance Claim Form |
Form and Instruction | Modified | Repair queued |
 1240-0044 Supporting Statement _20240611_MN clean.docx |
Supporting Statement A | Uploaded 2024-06-11 | Repair queued |
| Privacy Act System of Records - FEC.docx |
Supplementary Document | Uploaded 2020-09-09 | Repair queued |
 20 CFR 725.405 BLBA Supporting Reg.doc |
Supplementary Document | Uploaded 2012-10-23 | Repair queued |
| 20 CFR 30.701 EEOICPA Supporting Reg.doc |
Supplementary Document | Uploaded 2012-10-23 | Repair queued |
| 20 CFR 10.801 FECA - Supporting Reg.doc |
Supplementary Document | Uploaded 2012-10-23 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 43805 |  Health Insurance Claim Form |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | DOL/OWCP |
| OMB Control No | 1240-0044 |
| Type of Information Collection | Extension without change of a currently approved collection |
| Previous ICR Reference No | 202312-1240-004 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |