CM-2970a Operator Response to Notice of Claim

Operator Response To

Notice of Claim

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
Potentially Liable Operator's Name				Insurer's Name			Policy No.

This information 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 725.408). Please check appropriate boxes and provide requested information. While you are not required to respond, if you fail to do so within 30 days of your receipt of the Notice of Claim you shall not be allowed to contest your liability for the payment of benefits on any of the five specific grounds set forth below in Section B. (20 CFR 725.408). You must send a copy of this response to the claimant by regular mail.

1. Acceptance of Liability

The named potentially liable operator is the responsible operator within the meaning of the Black Lung Benefits Act.

2. Controversion of Liability

Indicate whether the named potentially liable operator accepts or denies the assertions that follows. Acceptance of these assertions is not necessarily an acceptance of liability. You may still contest your liability on any other available grounds.

^Accepts Denies

The operator was an operator for any period after 6/30/73.

This operator employed the miner as a miner for a cumulative period of not less than one year.

The miner was exposed to coal mine dust while working for this operator.

The miner's employment with this operator included at least one working day after December 31, 1969.

This operator or its insurer is financially capable of assuming liability for the payment of benefits.

Time period for submission of evidence. Within 90 days of the date on which you received the Notice of Claim, you may submit documentary evidence in support of your positions asserted in Section B. For any of the assertions you denied, you must submit all relevant documentary evidence within this 90- day period. The time period may be extended for good cause shown if an extension request is filed with the district director prior to expiration of the 90-day period. You must include a statement of reasons why you need additional time with your extension request.

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 15 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.

3. Additional Information

Please answer the questions below. If the space provided for any response is inadequate, please continue your response on a blank sheet of paper and attach it to the form. If you are unable to respond to these questions within the 30-day period for accepting or denying the operator assertions set forth in Section B above (i.e. within 30 days of receipt of the Notice of Claim), you should return this form in compliance with the 30-day time limitation and provide the information requested in this section within 90 days of your receipt of the Notice of Claim.

1. The miner was employed by the named potentially liable operator (list all periods of employment):

From: ^To:

Miner's Job Classification(s)/ Type(s) of Work Performed

Time Performed (Beginning and Ending Dates)

Name and Location of Mine or Facility

(County and State)

2. 

   
   

   
   

   
   

   
   

   
   

   
   

   
   

   
   

   Our records indicate that the potentially liable operator is insured as indicated in the header of page 1. If this information is incorrect, please complete information below.

Insurance Carrier(s) ^{Policy Number} Dates of Coverage

3. Is the named potentially liable operator affiliated in any way with any of the other firms identified in the Notice of

Claim as potentially liable operators?

Yes No

If yes, please explain the nature of the relationship.

4. 
   Has the named potentially responsible operator transferred or sold its mine, mines, or coal mining business, or substantially all of the assets thereof, to another person or business organization? ^{Yes No If yes, please} explain the details of the transaction(s), including the name(s) of the person(s) or organization(s) acquiring the property.

5. 
   

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

   
   

   
   

   Please set forth any additional facts regarding potential liability you would like to have considered.

N

CM-2970a