Form CM-908 Notice of Termination, Suspension, Reduction, or Increas

Print

Reset

Notice of Termination,
Suspension, Reduction, or
Increase In Benefit Payments

U.S. Department of Labor

Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

Privacy Act Statement: In accordance with the Privacy Act of 1974, as amended, (5 U.S.C. a), you are hereby notified that:
This report is required by the Black Lung Benefits Act (30 U.S.C. 90 1 et. seq.) and is mandatory. It is to be completed in full
and filed with the Office of Workers' Compensation Programs within 16 days following the termination of benefits, and
immediately following the suspension, reduction or increase of benefits are paid under Title IV of the Federal Mine Safety &
Health act of 1977, as amended to insure that correct benefits are paid. Failure to report can result in a civil penalty of not
more than $500 for each such failure or refusal.

Distribution copies to:
Payee, Operator, and
Department of Labor:

Name and Address of Payee (Please Print) Include ZIP Code
Name
Address Line 1

City

Address Line 2

State

U.S. Department of Labor
DCMWC Central Mailroom
PO Box 8307
London, KY 40742-8307

ZIP

Payee E-mail Address
2.a. Case ID

1. Name of disabled or deceased miner

2.b. DOL Claim Number

3. Name of coal miner operator
5. Action taken:

OMB No. 1240-0030
Expires: XX-XX-XXXX

4. Name of insurance carrier

Terminated

Suspended

Reduced

Increased

6. Reasons why action taken:

a. Date of Last Payment
(mm/dd/yy)

b. Amount of Last Payment

7. Summary of Payments
a. Name of Payee

c. Amount of Reduced/
Increased Payment

b. From

8. Signature and address of person issuing this notice

c. To

d. Date Benefits Will
Resume (mm/dd/yy)

d. Date Benefits
Will Resume

e. Date of This Notice
(mm/dd/yy)

e. Amount Paid
Per Month

f. Total

9. Title

Signature
Address Line 1

10. Telephone number

Address Line 2
City

State

ZIP

11. E-mail Address

Public Burden Statement
Public reporting burden for this collection of information is estimated to average 12 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
Office of Workers' Compensation Programs, U.S. Department of Labor, Room C-3520, 200 Constitution Avenue, NW., Washington, DC. 20210. DO
NOT SEND THE COMPLETED FORM TO THIS OFFICE.
Notice
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from
DCMWC in the form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will provide you
with copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes
to account for the limitations of your disability. Please contact our office or your claims examiner to ask about this assistance.
Note: According to the Paperwork Reduction Act of 1995, persons are not required to respond to this collection of information unless it displays a
currently valid OMB control number.
U.S. GPO:2001-479-595/89873

Form CM-908 (Rev. XX-2015)