Form CM-911 Miner's Claim for Benefits Under the Black Lung Benefits

Miner's Claim For Benefits Under
The Black Lung Benefits Act

U.S. Department of Labor

Office of Workers' Compensation Programs

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I hereby claim all benefits which may be payable to me under the Black Lung Benefits Act. I also hereby apply on
behalf of my family for any benefits that may be payable under the Act.

Print
OMB No. 1240-0038
Expires: 09-30-2011

IMPORTANT: No benefits may be paid under the Black Lung Benefits Act, unless a completed application form has been (FOR DOL USE)
received. However, disclosure of your Social Security Number is voluntary; the failure to disclose such number will not
result in the denial of any right, benefit or privilege to which an individual may be entitled. Collection of the information
on this form is authorized by law (30 U.S.C. 901, et. seq.). This information is required to obtain a benefit.
2. Miner's Social Security Number

1. Miner's full name (First, middle, last)

First Name

M.I.

Last Name
4. Highest grade miner completed in school

3. Miner's date of birth (Month, day, year)

5. Have you (or someone on your behalf) ever filed a claim for Federal
Black Lung benefits before?
Yes

6. Decision made (If more than one claim filed, identify
and show disposition of each in item 18, "Remarks")

No

7. Are you still working in or around coal mines?

Allowed

Denied

Withdrawn

Pending

Yes

If "yes," answer only c.

No

If "no," answer a-c.

b. Why did you stop working in or around coal mines or in a coal
a. When did you stop working in or around coal mines or a coal
preparation facility in the extraction, transportation or preparation
preparation facility in the extraction, transportation or preparation of
of coal, or in coal mine construction or maintenance in or around
coal, or in coal mine construction or maintenance in or around a coal
a coal mine?
mine?

c. Have you ever been transferred from your regular coal mine job
to lighter duty?
if "yes,'' provide date and reasons
No
Yes

why you were transferred. Use
space in item 18, "Remarks".

8. How many years have you worked in or around coal mines, or in
a coal preparation facility in the extraction or preparation of coal,
or worked in coal mine construction or transportation in or around
a coal mine?
To the best of your knowledge

list your complete coal mine Employment History on Form CM-91 1 a.

NOTE: If available evidence is not sufficient to arrive at a determination, you may be requested to have an independent medical examination
at no expense to you. Should the Department of Labor obtain information useful to your physician for treatment, such information may be
furnished to that physician.
9. Describe briefly any disability you believe you have due to pneumoconiosis (Black Lung) or other respiratory or pulmonary disease
resulting from coal mine employment. Specifically, what aspect(s) of your regular job in the coal mines are you physically unable to
perform as a result of your disability?

Form CM-911
Rev. Sept. 1998

NOTE: The amount of any state or Federal Workers' Compensation/Occupational Disease benefits you are receiving based on your disability
due to coal workers' pneumoconiosis will be subtracted from your benefits under Part C of the Black Lung Benefits Act.
10. Have you filed a workers' compensation claim under any state or Federal law on account of your disability, due to coal workers'
pneumoconiosis?
(if "yes," complete items a through j).
Yes
No
b. Approximate date of filing:

a. With what State or Federal agency was the claim filed?

c. Claim No. (if known):

e. Employer against whom Workers' Compensation Claim was filed?

d. Decision made
Pending

Denied

Allowed
f. Amount of payment:

g. Date payment began:
per week

Weekly: $

Date payment ended:

per

Other: $

h. Did you pay any attorney's fees or legal fees in securing your
workers' compensation award?

i . I f you have received a lump-sum payment based on you
compensation claim, please indicate the following:
Period covered (fill in below):

Yes

No

Amount: $

From:

To:

j. Do you receive any medical treatment benefits as part of your Workers' Compensation benefits?

Yes

No

NOTE- The amount of your earnings, either as an employee or from self-employment, will help us to determine the correct amount of black
lung benefits to which you may be entitled. This information is required by the 1981 Amendment to the Black Lung Benefits Act.
11 a. Enter the names and addresses of all persons, companies, or government agencies for which you worked during the previous calendar
year. If self-employed, so indicate.
Work Began
Month, Year

Name and Address of Employer

name:
line 1:
line 2:

city:
state:

Work Ended
Month, Year

Approximate
Earnings

zip:

b. How much do you expect your total earnings to be this year? (Count all of your earnings beginning with the first of the year and all
expected earnings through the end of this year.) $
Yes

12. Are you married now?

No

(if "Yes'' Complete items a-f.)

a. Date of marriage

(if "No" go to item 13).

b. Your spouse's first and maiden name (Print)

First Name

c. Spouse's birth date

Maiden Name

Yes

SSN:
e. Are you under a court order to make support payments to your spouse?
Yes

d. Do you and your spouse live together?

No

f . Do you make regular support payments to your spouse?

Yes

No

No

Yes

(if "yes", attach a copy of the order)

13. Were you previously married?

No (If "no", answer items e
and f)

(if "yes", indicate amount)
per

$

(week, month, other)

(if "yes" answer a through f)

a. Full Name of your previous spouse:
First Name
M.I. Last Name

b. Date married
(Month, day, year)

c. Place married (City & State)

d. How marriage ended: (death, divorce)

e. Date marriage ended:

f. Place marriage ended (City, State)

If prior marriage ended by divorce and you were married for 10 years before the divorce action, answer questions 14 and 15.
14. Are you under a court order to make support payments to a

divorced spouse?
Yes

No

(If "yes", attach a copy of the orders)

15. Do you make substantial contributions to a divorced spouse?
Yes
$

No (if "yes", indicate amount)
per
(week, month, other)

List All Such Children In Order Of Birth
Beginning With The Oldest

16. Do you have any Unmarried children who are:

Yes

No

M

F

OTHER

Age 18 or older and disabled

Date of Birth

STEPCHILD

No

ADOPTED

Age 18-23 and attending school
Yes

LEGITIMATE

No

DISABLED

Yes

STUDENT

(Use "Remarks' space Item 18 If space below Is insufficient.)
Check (X) If
Check (X) If
child 18 or over
that shows child's
sex of
Is student or
relationship to you
child
disabled

Under age 18

(Mo., day, yr.)
Full name of child:
SSN:
Full name of child:
SSN:
Full name of child:
SSN:
Full name of child:
SSN:
If Any Child Named Above Does Not Live With You, Enter The Name And Address Of The Person Or Organization With Whom The
Child Lives in item 18, *Remarks".
17. The events listed below may affect the amount of your Federal Black Lung Benefits:
your condition improves; or
You become entitled to receive workers' compensation or occupational disease payments due to disability on account of
pneumoconiosis; or
The amount of any of the benefits described above to which you are entitled changes; or
You work in or around coal mines or in any other employment, including self-employment.
The events listed below relating to your dependents may also affect the amount of your Federal Black Lung Benefits:
A dependent marries, divorces, dies, or is adopted by someone else; or
A child 18-23 stops attending school, or in the case of a disabled child 18 or older, the disabling condition improves.
It is IMPORTANT that you report PROMPTLY any of the above events which occur.
Do you agree to notify the Department of Labor if any of the above events occur?

Yes

No

18. Remarks: (You may use this space for any explanations. if you need more space attach a separate sheet.)

19. Do you authorize any physician, hospital, agency, employer or other organization (including the Social Security Administration) to disclose
to the Department of Labor any medical records, or Information about your disability or any other information pertinent to your claim?

Yes

No

20. Do you authorize the Department of Labor to give information about the decision on your Black Lung Benefits claim to the Workers'
Compensation, Unemployment Compensation, or Disability insurance agency of your State for use in connection with a claim you may
have with that agency?

Yes

No
SIGNATURE OF MINER

I hereby certify that the information given by me on and in connection with this form is true and correct to the best of my knowledge and belief.
I am also fully aware that any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any
benefit or payment under this title shall be guilty of a misdemeanor and on conviction thereof shall be punished by a fine of not more than
$1,000, or by imprisonment for not more than one year or both.
21. Signature of Claimant (First, middle, last)

22. Date (Month, day, year)

23. Mailing Address (Number, street, Apt. No., P.O. Box or Rural Route)

24. City and State

25. Zip Code

27. Telephone Number (Include area code)

26. County Where You Now Live

Witnesses are required ONLY if this application has been signed by mark (X) above. if signed by mark (X), two witnesses to the signing
who know the applicant must sign below, giving their full address.
28. Signature of witness

29. Signature of witness

30. Address (Number, street, city, state & zip code)

31. Address (Number, street, city, state & zip code)

city:
state:

zip:

city:
state:

zip:

Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
PRIVACY ACT NOTICE
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a) you are hereby notified that (1) the Black Lung Benefits Act (BLBA)
(30 U.S.C. 901 et. seq.) as amended, is administered by the Office of Workers' Compensation Programs (OWCP) of the U.S. Department of
Labor, which receives and maintains personal information, relative to this application, or claimants and their immediate families.
(2) information obtained by OWCP will be used to determine eligibility for the amount of benefits payable under the BLBA; (3) information may
be given to coal mine operators potentially liable for payment of the claim, or to the insurance carrier or other entity which secured the
operator's compensation liability; (4) information may be given to the physicians or medical service providers for use in providing treatment,
making evaluations and for other purposes relating to the medical management of the claim; (5) information may be given to the Department
of Labor's Office of Administrative Law Judges, or other person, board or organization, which is authorized or required to render decisions
with respect to the claim or other matters arising in connection with the claim; (6) information may be given to Federal, state or local agencies
for law enforcement purposes, to obtain information relevant to a decision under the BLBA, to determine whether benefits are being or have
been paid properly, and, where appropriate, to pursue administrative offset and/or debt collection actions required or permitted by law; (7)
disclosure of the claimant's Social Security Number (SSN) or tax identifying number (TIN) on this form is voluntary. The SSN and/or TIN
and other information maintained by the OWCP may be used for identification and for other purposes authorized by law; (8) failure to disclose
all requested information may delay the processing of this claim or the payment of benefits, or may result in an unfavorable decision or a
reduced level of benefits.
COMPUTER MATCHING PROGRAM: The Department of Labor conducts computer matches with the Department of Health and Human Services
and the Department of Veterans Affairs. Any information provided by applicants for and recipients of financial assistance or payments under
Federal benefit programs may be subject to verification through computer matches which the Department of Labor conducts with these
agencies.
Public Burden Statement
Public reporting burden for this collection of information is estimated to average 45 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 N-3464, 200 Constitution Avenue,
NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.