1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History

Miner's Claim for Benefits Under the Black Lung Benefits Act CM-911 and Employment History CM-911a

OMB: 1240-0038

IC ID: 13681

Documents and Forms

Document Name Document Type
Form CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form
Form CM-911 1) Miner's Claim for Benefits Under the Black Lung Benefits Act; 2) Employment History Form
CM-911 Miner’s Claim for Benefits Under The Black Lung Benefits Act cm-911_Spanish -Final.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-911a Employment History cm-911a_Spanish-Final.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-911 Miner’s Claim for Benefits Under The Black Lung Benefits Act CM-911 Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-911a Employment History CM-911a Form.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form