Form CM-921 Instructions for Completion of Form CM-921

U.S. DEPARTMENT OF LABOR
Employment Standards Administration
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

OMB No. 1215-0059
Expires: 03-31-2007

Instructions For Completion of Form CM-921

Reports of Coverage for Policies of Insurance Under Title IV of the Federal Coal Mine
Health and Safety Act of 1969, as Amended

Under the Regulation of the Federal Coal Mine Health and Safety Act of 1969, as amended, each
carrier or State fund providing coverage to operators under the provisions of such Act is required
(20 CFR 726.208 - 726.12) to report to the Office of Workers' Compensation Programs each policy
and endorsement issued by it to an operator who carriers on coal mining operations in a named
State or States. The report must be made on Form CM-921 and filed with the Office of Workers'
Compensation Programs at the time and manner specified. A sample report (Form CM-921) is
included for reference. Each carrier should print its name on Form CM-921 in the place where
indicated. The balance of the information on the report should be completed by underwriters at the
time of issuance of a policy and the form then submitted to the U.S. Department of Labor,
Office of Workers' Compensation Programs, Washington, DC, 20210.
Cancellation of a contract or policy of insurance issued under the authority of the said Act shall not
become effective otherwise than as provided by the provisions under 33 U.S.C. 936(b) which requires
that the carrier state fund must submit a notice to the Office of Workers' Compensation Programs
and to the operator of the proposed cancellation 30 days before such cancellation is intended to be
effective.

1. NAME OF EMPLOYER - The correct name of the coal mine operator must be written in full,
as well as the trade name, if the business is conducted under a trade name; if partnership, the
correct partnership name must be shown.
a. A separate card report for each operator covered shall be submitted. The name of only one
operator shall appear on each report.

Form CM-921
Rev. Dec 2001

- 2 -

EXAMPLE
All on one Card:
WRONG

A Separate Card
for Each:

Southern Coal Company; John Brown and
James Black T/A Brown and Black
Company; and Brown and Black Southern
Coal Company.
(1) Southern Coal Company
(2) John Brown and James Black T/A
Brown and Black Company
(3) Brown and Black Southern Coal
Company

b. In no case shall the expression "et al" or similar abbreviations or indications of undisclosed
operators be used. The correct name of the operator, whether individual, firm, or corporation,
shall be shown.
2. ADDRESS - The coal mine operator's address must be shown.
3. POLICY NUMBER - Current insurance policy number.
4. COVERAGE DATES - The beginning and expiration dates of policies must be clearly indicated.
They should be written plainly, such as "July 1, 1994 to July 1, 1995" or other proper dates, and
uncertain abbreviations avoided. For example, "7/1/94 - 95," would be considered uncertain.
Policies should cover a period of one year; if card indicates a shorter term, a satisfactory letter of
explanation should accompany the card.
5. LOCATIONS OF INSURED OPERATIONS - List all States with coal mine operations insured under
the terms of the policy.
6. INSURANCE CARRIER
No contract or policy of insurance issued by a state fund under the Act shall be cancelled prior
to the date specified in each contract or policy for its expiration until at least thirty days have
elapsed after a notice of cancellation has been sent to the OWCP and to the operator in
accordance with the provision of 33 USC 936(b).
7. ADDRESS
8.

TELEPHONE

9.

SIGNATURE

a. Notification of cancellation or reinstatement of a policy must be sent to the OWCP in letter
form. Cancellations by card form will not be accepted, and will be returned to the carrier.

- 3 b. When a rewrite of a policy is made, the card report of the new insurance coverage should
bear the statement, "rewrite of Policy Number
." This information should be provided
in the policy number box, in addition to the new policy number. This will prevent misunderstandings
and avoid time-consuming correspondence to the carrier for explanations of existence of two or
more policies.
COLOR AND SIZE OF CARD - Each carrier has the responsibility for having Form CM-921 available
for use by its own underwriting staff. Such forms must be printed (at the carrier's own expense)
upon a standard 80 digit IBM card composed of blue cardboard and following the approved OWCP
format. (See sample).
Notice of Issuance of Insurance Policy
1. Mine operator
2. Address (include Street, City, County, State, ZIP Code)

3. Policy Number

4. Policy Dates

a. Beginning

b. Ending

Report is made of this issue of approved form of policy and endorsement under the Black Lung Benefits Act. This report is authorized by
law. (30 U.S.C. 901 01 Sec.) Response is required by 20 C.F.R. 726.208 is used to identify the insurance carrier.
5. Coverage is provided for operations in the following states:
6. Insurance Carrier

(DO NOT WRITE IN THIS SPACE)

7. Address
OWCP No.
Cancel Date:

8. Telephone Number
9. Authorized Signature for Carrier

Completed card should be forwarded to the U.S. Department of Labor, Office of Workers' Compensation Programs, Division of Coal Mine
Workers' Compensation, Washington. D.C. 20210.
Form CM-921
(COMPLETE REVERSE SIDE)

Indicate below the name and location of the insured mine(s).

NAME OF MINE

NAME LOCATION

Public Burden Statement
Public reporting burden for this collection of information is estimated to average 10 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 Mine Workers' Compensation, Room C3520, 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.