CM-2970a

Operator Response To
Notice of Claim
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U.S. Department of Labor
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Employment Standards Administration
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

Claimant's Name

Miner's Name
Potentially Liable Operator's Name

Claim Number

Insurer's Name

OMB No. 1215-0058
Expires: 10-31-2007
Policy No.

This information is authorized by the Black Lung Benefits Act (30 U.S. C. 901 et seq.) (20 CFR 725.408). Please check appropriate
boxes and provide requested information. While you are not required to respond, if you fail to do so within 30 days of your receipt
of the Notice of Claim you shall not be allowed to contest your liability for the payment of benefits on any of the five specific
grounds set forth below in Section B. (20 CFR 725.408). You must send a copy of this response to the claimant by regular mail.
A. Acceptance of Liability
The named potentially liable operator is the responsible operator within the meaning of the Black Lung Benefits Act.
B. Controversion of Liability
Indicate whether the named potentially liable operator accepts or denies the assertions that follows.
Acceptance of these assertions is not necessarily an acceptance of liability. You may still contest your liability on any
other available grounds.
Accepts

Denies

The operator was an operator for any period after 6/30/73.

This operator employed the miner as a miner for a cumulative period of not less
than one year.
The miner was exposed to coal mine dust while working for this operator.

The miner's employment with this operator included at least one working day after
December 31, 1969.

This operator or its insurer is financially capable of assuming liability for the payment
of benefits.

Time period for submission of evidence. Within 90 days of the date on which you received the Notice of Claim, you may submit
documentary evidence in support of your positions asserted in Section B. For any of the assertions you denied, you must submit all relevant
documentary evidence within this 90-day period. The time period may be extended for good cause shown if an extension request is filed with
the district director prior to expiration of the 90-day period. You must include a statement of reasons why you need additional time with your
extension request.
Public Burden Statement
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the U.S. Department of Labor, Division of Coal Miner Workers' Compensation, Room C3526, 200 Constitution Avenue,
N.W., Washington, D.C. 20210. Note: Persons are not required to respond to this collection of information unless it displays
a currently valid OMB control number. (DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.)
Form CM-2970a
Rev.Jan.2001

C. Additional Information
Please answer the questions below. If the space provided for any response is inadequate, please continue your response on a blank sheet of
paper and attach it to the form. If you are unable to respond to these questions within the 30-day period for accepting or denying the operator
assertions set forth in Section B above (i.e. within 30 days of receipt of the Notice of Claim), you should return this form in compliance with the
30-day time limitation and provide the information requested in this section within 90 days of your receipt of the Notice of Claim.

1. The miner was employed by the named potentially liable operator (list all periods of employment):

To:

From:

Miner's Job Classification(s)/
Type(s) of Work Performed

Name and Location of Mine or Facility
(County and State)

Time Performed
(Beginning and Ending
Dates)

2. This named potentially liable operator is insured for its obligations under the Black Lung Benefits Act
as an approved self-insurer or
by a policy or contract of insurance as follows:
Insurance Carrier(s)

Policy Number

Dates of Coverage

3. Is the named potentially liable operator affiliated in any way with any of the other firms identified in the Notice of
Claim as potentially liable operators?
If yes, please explain the nature of the relationship.
Yes
No

4. Has the named potentially responsible operator transferred or sold its mine, mines, or coal mining business, or
Yes
No If yes, please
substantially all of the assets thereof, to another person or business organization?
explain the details of the transaction(s), including the name(s) of the person(s) or organization(s) acquiring the property.

5. Please set forth any additional facts regarding potential liability you would like to have considered.

Name and Address of Firm Completing Form

Name of Person Completing Form
Title
Signature

Date