Form CM-905 Request for State or Federal Workers' Compensation Infor

Request for State or Federal U.S. DEPARTMENT of LABOR

Workers' Compensation Information Employment Standards Administration

Office of Workers' Compensation Programs

Division of Coal Mine Workers’ Compensation

The requested information is needed to process a claim under the Black Lung Benefits Act (30 U.S.C. 901 et. seq.). While completion of this form is voluntary, cooperation is needed in returning this form to determine the claimant’s eligibility under the Act.			OMB No. 1240-0032 Expires: xx-xx-xxxx
. IDENTIFICATION OF MINER (To be completed by DOL Claims Examiner)
TO:	1a. Name of Miner (First, Middle, Last)
	b. Name of Claimant (if different from miner)
	2.Address(Number, street, city, state, Zip code)
3. Employer's Name and Address	4. Miner's Social Security Number
	5. State or Federal Claim Number(s)
6. Signature of DOL Claims Examiner	7. Date(Month, day, year)
II. WORKERS' COMPENSATION INFORMATION (To Be completed by a State or Federal Workers' Compensation official)
Please complete all items as appropriate including item 5 if no claim number is provided. Forward the original to the Division of Coal Mine Workers' Compensation and retain a copy in your files for use in notifying the DCMWC of any changes in the beneficiary's workers' compensation status or rate.
8. Has the miner or his widow filed a claim for workers' compensation benefits due to pneumoconiosis or other chronic lung disease? [ ] Yes [ ] No (if "Yes", complete items 9,10 and 11, as appropriate.)		9. Status of Claim: [ ] Approved [ ] Denied [ ] Pending
10. Payment Information Date began: Expiration Date: Weekly Amount $ Lump sum amount $ representing settlement at $ per week for weeks beginning Date of Lump sum payment: Are medical treatment expenses covered? [ ] Yes [ ] No		11.Were Fees or Expenses paid out of the Award? a. attorney fees [ ] Yes $ amount [ ] No [ ] Unknown b. Other extraordinary [ ] Yes $ expenses (if "Yes" amount explain under [ ] No "Remarks") [ ] Unknown
12. Remarks:
Return To: U .S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs Division of Coal Mine Workers' Compensation		13. Signature and Title
		14 Date (Month, day, year)
Public Burden Statement Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time or 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, N. W., Washington, D.C. 20210. DO NOT SEND THE COMPLETE FORM TO THIS OFFICE

Original - Return to DCMWC Copy – Retain for Status or Rate Change Notification

CM-905

Rev. July 2007

Persons are not required to respond to this collection of information unless it displays a current valid OMB Control Number