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Agreement and Undertaking (Self-Insured Employer)

Form ID:

OWCP-1

Control ID:

OMB No. 1240-0039

Expiration date:

Wed, 30 Jun 2027 - 23:59

Forms

OWCP-1: Agreement and Undertaking (Self-Insured Employer)

Authorization of an employer to be self-insured under the Federal Coal Mine Health and Safety Act of 1969, as amended may be denied unless this agreement form has been received (30 USC 933). Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. The information collected will be used to assure the prompt payment of compensation benefits to injured employees and furnishing the information is required (20 CFR 726.110).