Form CM-921 Instructions For Completion of Form CM-921

U.S DEPARTMENT OF LABOR
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

OMB No. 1240-0048
Expires: 

Instructions For Completion of Form CM-921
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IMPORTANT: Carriers are NOT REQUIRED to submit this form if the insured coal mining operations are
conducted in a state that reports all workers’ compensation insurance coverage to the National Council
on Compensation Insurance (NCCI).
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1. NAME OF EMPLOYER - The correct name of the coal mine operator must be written in full, as well
as the trade name, if the business is conducted under a trade name; if partnership, the correct
partnership name must be shown.
a. A separate card report for each operator covered shall be submitted. The name of only one operator
shall appear on each report.

Form CM-921
Revised 6HSW
Previous version usable

EXAMPLE
All on one Card:
WRONG

Southern Coal Company; John Brown and
James Black T/A Brown and Black
Company; and Brown and Black Southern
Coal Company.

A Separate Card
for Each:

(1) Southern Coal Company
(2) John Brown and James Black T/A
Brown and Black Company
(3) Brown and Black Southern Coal
Company

b. In no case shall the expression "et al" or similar abbreviations or indications of undisclosed
operators be used. The correct name of the operator, whether individual, firm, or corporation,
shall be shown.
2. FEDERAL EMPLOYER IDENTIFICATON NUMBER - List the operator's FEIN or Tax ID.
3. ADDRESS - The coal mine operator's address must be shown.
4. POLICY NUMBER - Current insurance policy number.
5. COVERAGE DATES - 7KHEHJLQQLQJDQGH[SLUDWLRQGDWHVRISROLFLHVPXVWEHFOHDUO\LQGLFDWHG
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Form CM-921
Revised 6HSW
Previous version usable

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Notice of Issuance of Insurance Policy
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

1. Mine operator

2. Operator's Federal Employer Identification Number

3. Address (include Street, City, County, State, ZIP Code)

___________________________________________________________________________________________________________________
4. Policy Number
5. Policy Dates
a. Beginning
b. Ending
________________________________________________________________________________________________
Report is made of this issue of approved form of policy and endorsement under the Black Lung Benefits Act. This report is authorized by law
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____________________________________________________________________________________________________________________ 6.
Coverage is provided for operations in the following states:

_____________________________________________________________________________________________
7. Insurance Carrier
8. Address
9. Telephone Number
10. Authorized Signature for Carrier ____________________________

(DO NOT WRITE IN THIS SPACE)
OWCP No.:
Cancel Date:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Completed card should be forwarded to the U.S. Department of Labor, Office of Workers' Compensation Programs, Division of Coal Mine Workers'
Compensation, 200 Constitution Ave, N.W,6XLWH&'&0:&:DVKLQJWRQ'&RUILOHGHOHFWURQLFDOO\E\VXEPLWWLQJWR'&0:&
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(COMPLETE REVERSE SIDE)

Indicate below the name and location of the insured mine(s) and subsidiaries
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NAME AND LOCATION OF SUBSIDIARY

_____________________________________________

________________________________________________

_____________________________________________

________________________________________________

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_____________________________________________

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_____________________________________________

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Public Burden Statement
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Form CM-921
Revised 6HSW
Previous version usable