Information Collection

Carrier's Report of Issuance of Policy

IC 190307 under ICR 202506-1240-002 · OMB 1240-0004.

Documents and Forms

Document Name Document Type
Form LS-570 Carrier's Report of Issuance of Policy Form
Form LS-570 Carrier's Report of Issuance of Policy Carrier's Report of Issuance of Policy Form
LS-570 Carrier's Report of Issuance of Policy ls-570.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-570.pdf Form
LS-570 Carrier's Report of Issuance of Policy ls-570.pdf www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-570.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Carrier's Report of Issuance of Policy	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR CFR 703.118 20 CFR CFR 703.116 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-570	Carrier's Report of Issuance of Policy	ls-570.pdf	https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-570.pdf	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: n/a	FR Citation: 81 FR 25863

Number of Respondents: 400	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 98 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,500	0	1,500
Annual IC Time Burden (Hours)	25	0	25
Annual IC Cost Burden (Dollars)	19	4	15

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.

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