Application for Self-Insurance Under the Black Lung Benefits Act

OMB 1240-0057

OMB 1240-0057

This information collection is essential to the mission of OWCP’s Division of Coal Mine Workers’ Compensation, which administers the Black Lung Benefits Act (BLBA), 30 U.S.C. 901 et seq. The statute grants the Department authority to authorize and regulate coal mine operators who wish to self-insure their BLBA liabilities. 30 U.S.C. 933. This information collection would provide OWCP with sufficient information to determine whether a coal mine operator should be (or continue to be) authorized to self-insure. The information would also allow OWCP to determine the security amount a coal mine operator must deposit to guarantee that it will be able to meet its BLBA liabilities.

The latest form for Application for Self-Insurance Under the Black Lung Benefits Act expires 2022-07-31 and can be found here.


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