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Federal forms, ICRs, and supporting documents

Information Collection

Health Insurance Claim Form

IC 43805 under ICR 202503-1240-003 · OMB 1240-0044.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

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Health Insurance Claim Form
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 10.801 20 CFR 725.704 20 CFR 725.405 20 CFR 725.715 20 CFR 30.701 20 CFR 725.701 20 CFR 725.406(e)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction OWCP-1500 Health Insurance Claim Form 1240-0044 Health Insurance Claim Form (OWCP- 1500).pdf http://www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf Yes No Fillable Printable

Health Health Care Services

DOL/GOVT-1(FECA); DOL/OWCP-2(BLBA); DOL/OWCP-11(EEOICPA)   81 FR 25776

43,706 0
   
Private Sector Businesses or other for-profits
 
   67 %

  Approved 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 3,544,050 0 0 0 0 3,544,050
Annual IC Time Burden (Hours) 413,473 0 0 0 0 413,473
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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