Notice of Issuance of Insurance Policy

OMB 1240-0048

The CM-921 provides insurance carriers with the means to supply DCMWC with information showing that a responsible coal mine operator is insured against liability for payment of compensation under the Federal Black Lung Benefits Act.

The latest form for Notice of Issuance of Insurance Policy expires 2023-12-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CM-921 Notice of Issuance of Insurance Policy Form
Form CM-921 Notice of Issuance of Insurance Policy Form
SS 1240-0048 9.11.23_MN-MM.docx Supporting Statement A
SS 1240-0048 9.11.23_MN-MM.docx Supporting Statement A
Justification CM-921.docx Justification for No Material/Nonsubstantive Change
Justification CM-921.docx Justification for No Material/Nonsubstantive Change
2023 30-Day FRN_1240-0048.pdf Supplementary Document
2023 30-Day FRN_1240-0048.pdf Supplementary Document
2023 60-Day FRN_1240-0048.pdf Supplementary Document
2023 60-Day FRN_1240-0048.pdf Supplementary Document
System of Record Notice-DOL OWCP-2.pdf Supplementary Document
System of Record Notice-DOL OWCP-2.pdf Supplementary Document
20_CFR_Part_V_Subpart_C_726.208-213.pdf Supplementary Document
20_CFR_Part_V_Subpart_C_726.208-213.pdf Supplementary Document
30 USC Section 933.pdf Supplementary Document
30 USC Section 933.pdf Supplementary Document
NCCI screen shot.docx Supplementary Document
NCCI screen shot.docx Supplementary Document
Notice of Issuance of Insurance Policy Form
Notice of Issuance of Insurance Policy Form

202401-1240-011 Approved without change	No material or nonsubstantive change to a currently approved collection	2024-01-31
202306-1240-002 Approved without change	Revision of a currently approved collection	2023-10-04
201910-1240-005 Approved with change	Reinstatement without change of a previously approved collection	2020-02-06
201603-1240-002 Approved without change	Revision of a currently approved collection	2016-07-29
201303-1240-001 Approved without change	Revision of a currently approved collection	2013-05-29
201004-1240-008 Approved without change	Extension without change of a currently approved collection	2010-04-23
201003-1240-048 Approved without change	Extension without change of a currently approved collection	2007-01-19