Form CM-921 Notice of Issuance of Insurance Policy

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

OMB No. 1240-0048
Expires: 00/00/0000

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 Regulations 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 carries 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 annually. A sample report (Form CM-921) is included for reference. Each carrier should
complete the form at the beginning of a new coverage period and submit it to the following address:
US Department of Labor, Office of Workers' Compensation Programs, Division of Coal Mine Workers’
Compensation, 200 Constitution Ave., Washington, DC, 20210.
IMPORTANT: Carriers are NOT REQUIRED to submit this form if the insured coal mining operations
are conducted in a state that reports all workers’ compensation insurance coverage to the National
Council on Compensation Insurance (NCCI).
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
Revised March 2013
Previous version usable

EXAMPLE
All on one Card:
WRONG

Southern Coal Company; John Brown and
James Black T/A Brown and Black
Company; and Brown and Black Southern
Coal Company.

A Separate Card
for Each:

(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. FEDERAL EMPLOYER IDENTIFICATON NUMBER - List the operator's FEIN or Tax ID.
3. ADDRESS - The coal mine operator's address must be shown.
4. POLICY NUMBER - Current insurance policy number.
5. 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.
6. STATES OF INSURED OPERATIONS - List all States with coal mine operations insured under the
terms of the policy. List names and locations of covered mines and subsidiaries on the reverse.
7. 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 U.S.C. 936(b).
8. ADDRESS
9. TELEPHONE
10. SIGNATURE
a. Notification of cancellation or reinstatement of a policy must be sent to the OWCP in letter
form. Cancellation by card form will be accepted, and will be returned to the carrier.

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 following the approved OWCP format. (See sample).
Notice of Issuance of Insurance Policy
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

1. Mine operator

2. Operator's Federal Employer Identification Number

3. Address (include Street, City, County, State, ZIP Code)

___________________________________________________________________________________________________________________
4. Policy Number
5. 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 and is used to identify the insurance carrier.
____________________________________________________________________________________________________________________
6. Coverage is provided for operations in the following states:

_____________________________________________________________________________________________
7. Insurance Carrier
8. Address
9. Telephone Number
10. Authorized Signature for Carrier ____________________________

(DO NOT WRITE IN THIS SPACE)
OWCP No.:
Cancel Date:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Completed card should be forwarded to the U.S. Department of Labor, Office of Workers' Compensation Programs, Division of Coal Mine Workers'
Compensation, 200 Constitution Ave, N.W,, Washington, DC, 20210.
(COMPLETE REVERSE SIDE)

Indicate below the name and location of the insured mine(s) and subsidiaries
NAME AND LOCATION OF MINE
NAME AND LOCATION OF SUBSIDIARY

_____________________________________________

________________________________________________

_____________________________________________

________________________________________________

_____________________________________________

________________________________________________

_____________________________________________

________________________________________________

_____________________________________________

________________________________________________

_____________________________________________

________________________________________________

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, DC, 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 COMPLETE FORM TO THIS OFFICE.

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