Application for Self-Insurance Under the black Lung Benefits Act

Application for Self-Insurance Under the Black Lung Benefits Act

OMB: 1240-0057

IC ID: 234819

Documents and Forms

Document Name Document Type
Instructions_for_Applying_or_Renewing_Self-insurance.for OCIO.1.15.19.pdf Instruction
CM-2017 Application or Renewal of Self-Insurance Authority cm-2017 Form.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-2970a Financial Summary for Self-Insured Operators cm-2017a Form.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-2017b Report of Claims Information for Self-Insured Operators cm-2017b.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form