CM-2017 Application or Renewal of Self-Insurance Authority

Application or Renewal of
Self-Insurance Authority

U.S. Department of Labor
Office of Workers' Compensation Programs

www.dol.gov/owcp/dcmwc/index.htm
OMB No. 1240-0057
Expires: 11/30/2025

Use this form to request that the Office of Workers' Compensation Programs (OWCP) authorize your company (or continue to authorize you) to
self-insure your obligations under the Black Lung Benefits Act (BLBA), 30 USC 901-944. 30 USC 933(a)(1). OWCP will not consider any selfinsurance authorization request without a completed application. 30 USC 933(a)(1); 20 CFR 726.102, 726.112.
OWCP will use the information in this application to determine whether you possess sufficient ability to pay benefits, furnish medical services
and supplies, and meet all other obligations under the BLBA. 20 CFR 726.104. OWCP will also use this information to fix the amount of
security you must deposit to guarantee payment of benefits and all other obligations under the BLBA. 20 CFR 726.104-726.105.
INSTRUCTIONS: You must complete all items; please see the attached instructions for guidance. If you need more space than provided,
attach additional pages. Please specify the item you are answering on any additional sheet.
New applicants: The application must be accompanied by: (1) A copy of your certified consolidated financial statement for each of the past
three years. (2) Form CM-2017b, “Report of Claims Information.” (3) Form CM-2017a, “Financial Summary.” (4) A statement from your
insurance carrier(s) showing all BLBA benefits paid for the past three years. (5) A current, certified actuarial report on your existing and future
BLBA liabilities.
Renewal applicants: The application must be accompanied by: (1) A copy of your most recent certified consolidated financial statement. (2)
Form CM-2017b, “Report of Claims Information.” (3) Form CM-2017a, “Financial Summary.” (4) A current, certified actuarial report on your
existing and future BLBA liabilities unless you have provided one to OWCP within the past three years.
1. Name, address, and FEIN of parent company

FEIN:

Name
Addr1

City

Addr2

State

Zip

2. Name, address, and FEIN of each subsidiary company

Country

United States

FEIN:

Name
Addr1

City

Addr2

State

Zip

Country

United States

3. NATURE OF BUSINESS - Check all that apply:
Bituminous coal

Anthracite coal

Lignite coal

Sub-bituminous coal

Underground mining

Surface mining

Preparation plants

Coal transportation/coal mine construction

4. Information appearing in the columns below should relate to employees covered by the BLBA and for which self-insurance authorization is
requested.
a. Mine site names and locations
b. Subsidiary name mine site operates c. MSHA d. Mining
e. Number of f. Total payroll for
under
ID #
type
covered
covered employees for
employees
past three years
20**/20**/20**

Form CM-2017

5. If this application is granted, which form of security would you prefer to deposit?
501(c) 21 Trust
Indemnity Bond
Federal Deposit
Letter of Credit, in
conjunction with one of the
above securities
6. How do you intend to administer claims? (If you have checked "a", give name and address of persons responsible for claims handling, with
brief resume of their experience. If you have checked "b", give name and address of the Third Party
a. Deal directly with employees
Administrator, and describe the arrangements, including what, if any, experience the organization
has in administering claims under the BLBA.) You must provide the name, telephone number, and
b. Use a Third Party Administrator
email of the primary point of contact for BLBA claims.

7. Total Claims Data for Previous Three Years
20

20

20

a. # Claims awarded and accepted,
excluding Medical Benefits Only
claims
b. # Medical Benefits Only claims
being paid
c. # Claims awarded but
challenged at hearing or appellate
level
d. # New claims filed
e. Indemnity benefits paid
f. Medical benefits paid

$

$

$

$

$

$

8. Date of incorporation (mm/dd/yyyy)

9. State of incorporation

10. Date applicant was established (if not a corporation) (mm/dd/yyyy)

11. Did you succeed anyone? (If "Yes," state whom and explain the
transaction)
Yes
No

12. Has your corporate/business structure changed in the past three
years? (If “Yes,” explain the change)
Yes
No

13. Name of President

14. Name of Vice President

15. Name of Treasurer

16. Name of Secretary

17. Name, telephone number, and email address of Risk Manager

Telephone

Email

Form CM-2017
Page 2

18. I certify that I am an official of the Applicant, duly authorized to file this application, that I have carefully examined the foregoing statements,
and the facts in this application and required attachments are true.
I also certify that the Applicant will, if authorized to self-insure:
a. Comply with all statutory and regulatory obligations under the BLBA;
b. Make timely payments of benefits, including medical treatment benefits, required under effective orders;
c. Monitor claims administration by any insurance service organization or other claims handlers to be sure benefits are paid promptly;
d. Promptly comply with all OWCP requests for information necessary to determine self-insurance authorization and the amount of a
security deposit;
e. Make and maintain a security deposit, in a form and in an amount determined by OWCP, subject to OWCP's order; and
f. Advise OWCP immediately of any change in corporate or business structure, or sale of significant coal mining assets

(SEAL)
Signature

Telephone
20. Date of this application (mm/dd/yyyy)

19. Name and Title

DO NOT WRITE IN THE ITEMS BELOW

21. Date application received (mm/dd/yyyy)

22.OWCP Certification

Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to an information collection unless such collection
displays a valid OMB control number. We estimate that it will take an average of 2 hours per response to complete this collection of information,
including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Use of this form is optional; however, furnishing the information is required to obtain or retain
authorization to self-insure under the BLBA. Send comments regarding this burden estimate or any aspect of this information collection
process, including suggestions for reducing this burden, to the U.S. Department of Labor, 200 Constitution Avenue, NW, Suite C3520-DCMWC,
Washington, D.C. 20210 and reference the OMB Control Number.

Form CM-2017
Page 3