Fillable Miners Claim For Benefits printable pdf download

U.S. Department of Labor

Miner's Claim For Benefits Under

The Black Lung Benefits Act

Employment Standards Administration

Office of Workers' Compensation Programs

Reset

I hereby claim all benefits which may be payable to me under the Black Lung Benefits Act. I also hereby apply on

OMB No. 1215-0052

behalf of my family for any benefits that may be payable under the Act.

Expires: 08-31-08

(FOR DOL USE)

IMPORTANT: No benefits may be paid under the Black Lung Benefits Act, unless a completed application form has been

received. However, disclosure of your Social Security Number is voluntary; the failure to disclose such number will not

result in the denial of any right, benefit or privilege to which an individual may be entitled. Collection of the information

on this form is authorized by law (30 U.S.C. 901, et. seq.). This information is required to obtain a benefit.

1. Miner's full name (First, middle, last)

2. Miner's Social Security Number

First Name

M.I.

Last Name

3. Miner's date of birth (Month, day, year)

4. Highest grade miner completed in school

5. Have you (or someone on your behalf) ever filed a claim for Federal

6. Decision made (If more than one claim filed, identify

Black Lung benefits before?

and show disposition of each in item 18, "Remarks")

Allowed

Denied

Yes

Withdrawn

Pending

7. Are you still working in or around coal mines?

If "yes," answer only c.

Yes

If "no," answer a-c.

N o

b. Why did you stop working in or around coal mines or in a coal

a. When did you stop working in or around coal mines or a coal

preparation facility in the extraction, transportation or preparation of

preparation facility in the extraction, transportation or preparation

of coal, or in coal mine construction or maintenance in or around

coal, or in coal mine construction or maintenance in or around a coal

a coal mine?

mine?

c. Have you ever been transferred from your regular coal mine job

8. How many years have you worked in or around coal mines, or in

to lighter duty?

a coal preparation facility in the extraction or preparation of coal,

or worked in coal mine construction or transportation in or around

if "yes,'' provide date and reasons

N o

Yes

why you were transferred. Use

a coal mine?

To the best of your knowledge

space in item 18, "Remarks".

list your complete coal mine Employment History on Form CM-91 1 a.

NOTE: If available evidence is not sufficient to arrive at a determination, you may be requested to have an independent medical examination

at no expense to you. Should the Department of Labor obtain information useful to your physician for treatment, such information may be

furnished to that physician.

9. Describe briefly any disability you believe you have due to pneumoconiosis (Black Lung) or other respiratory or pulmonary disease

resulting from coal mine employment. Specifically, what aspect(s) of your regular job in the coal mines are you physically unable to

perform as a result of your disability?

Form CM-911

Rev. Sept. 1998

Miners Claim For Benefits

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