Information Collection

Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act

IC 13940 under ICR 202511-1240-002 · OMB 1240-0006.

Documents and Forms

Document Name Document Type
Form CA-278 Claims for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act Form and Instruction
Form WH-1 Notice of Injury or Disease and Claim for Benefits under the War Hazards Compensation Act Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act Form and Instruction
CA-278 Claims for Reimbursement of Benefit Payments and Claims CA-278 (Revised) 9.5.25.updated 02.26.26.pdf www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-278.pdf Form and Instruction
WH-1 Notice of Injury or Disease and Claim for Benefits under WH-1 (New).final. updated 2.26.26.pdf www.dol.gov/agencies/owcp/FECA/regs/compliance/forms Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	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 61.101 20 CFR 61.104

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-278	Claims for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards	CA-278 (Revised) 9.5.25.updated 02.26.26.pdf	https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/ca-278.pdf	Yes	Yes	Fillable Printable
Form and Instruction	WH-1	Notice of Injury or Disease and Claim for Benefits under the War Hazards Compensation Act	WH-1 (New).final. updated 2.26.26.pdf	https://www.dol.gov/agencies/owcp/FECA/regs/compliance/forms	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: DOL/GOVT-1	FR Citation: 81 FR 47418

Number of Respondents: 14	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,528	1,264	0	1,264
Annual IC Time Burden (Hours)	1,264	632	0	632
Annual IC Cost Burden (Dollars)	5,840	0	3,413	2,427

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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