Form CM-2970 Operator's Response To Schedule for Submission of Additi

OPERATOR RESPONSE TO SCHEDULE FOR THE SUBMISSION OF ADDITIONAL EVIDENCE

U.S. Department of Labor

Office of Workers' Compensation Programs

Division of Coal Mine Workers' Compensation

Miner's Name				Claimant's Name		DOL’s Case ID Number		OMB No. 1240-0033 Expires: XX-XX-XXXX
Responsible Operator's Name					Insurer's Name		Policy No.

This report is authorized by the Black Lung Benefits Act 30 U.S.C. 901 et seq. and the regulations of the U.S. Department of Labor governing the administration of such Act (20 CFR 725.412). Please check appropriate boxes below. While you are not required to respond, if you fail to do so within 30 days after the District Director's issuance of the Schedule for the Submission of Additional Evidence naming you as a responsible operator, you shall be deemed to have accepted liability for this claim (that is, that you will be responsible for payment of benefits to which the claimant is finally determined to be entitled) and to have waived your right to contest your liability in any further proceeding conducted with respect to this claim. You also will be deemed to have contested the claimant's entitlement to benefits.

1. Liability

The named responsible operator:

Agrees it is the responsible operator within the meaning of the Black Lung Benefits Act, liable for any benefits to which the claimant is finally determined to be entitled.

Disagrees with its designation as the responsible operator liable for this claim.

If you disagree, the Schedule for the Submission of Additional Evidence advises you of the time period within which you may submit evidence relevant to your liability, subject to the limitations imposed by 20 C.F.R. 725.408(b)(2). Absent extraordinary circumstances, no documentary evidence pertaining to liability shall be admitted in any further proceeding conducted with respect to this claim unless it is submitted to the district director in compliance with a Schedule for the Submission of Additional Evidence.

2. Claimant's Entitlement

The named responsible operator:

Accepts the claimant's entitlement to benefits. Contests the claimant's entitlement to benefits.

If you do not accept the claimant's entitlement to benefits, the Schedule for the Submission of Additional Evidence will advise you of the time period within which you may submit evidence relevant to the claimant's entitlement. If you enter no response in this section, you will be deemed to have contested the claimant's entitlement to benefits.

Name and Address of Firm Completing Form						Name of Person Completing Form Title
						Signature Date

TWO FILING OPTIONS:

1. To file electronically, submit completed form and accompanying documents to the COAL Mine Portal: https://eclaimant.dol-esa.gov/bl

2. To file by mail, submit completed form and accompanying documents to:

US Department of Labor

OWCP/DCMWC

PO Box 33610

San Antonio, TX 78265

Privacy Act Statement

The following information is provided in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. (1) Submission of this information is required under the Black Lung Benefits Act, 30 U.S.C. 901 et. seq., and implementing regulations . (2) The information will be used to determine eligibility for and the amount of benefits payable under the Act. (3) This information may be used by other agencies or persons handling matters relating, directly or indirectly, to processing this form including coal mine operators and their insurance carriers; contractors providing automated data processing or other services to the Department of Labor; representatives of the parties to the claim; and federal, state or local agencies. (4) Furnishing all requested information will facilitate the claims adjudication process, and the effects of not providing all or any part of the requested information may delay the process or result in an unfavorable decision. (5) This information is included in a System of Records, DOL/OWCP-2 and DOL/OWCP-9 published at 81 Federal Register 25765, 25858 and 25866 (April 29, 2016), or as updated and republished.

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 N-3464, 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.)

Notice

If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from OWCP 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 the claims examiner to ask about this assistance.

CM-2970

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