Form CM-2970a 

Rev. Oct. 2023

Operator Response To 

Notice of Claim U.S. Department of Labor

Office of Workers' Compensation Programs

Division of Coal Mine Workers' Compensation

Miner's Name: Claimant's Name: Claim Number: OMB No. 1240-0033 

Expires: 10/31/2026

Responsible Operator’s Name: Insurer's Name Policy No.

This information is authorized by the Black Lung Benefits Act 30 U.S.C. 901 et. Seq., and the regulations of the U.S. Department of Labor 

governing the administration of such Act (20 CFR 725.408). Please check appropriate boxes and provide requested information. While you are 

not required to respond, if you fail to do so within 30 days of your receipt of the Notice of Claim you shall not be allowed to contest your liability 

for the payment of benefits on any of the five specific grounds set forth below in Section B. (20 CFR 725.408). You must send a copy of this 

response to the claimant by regular mail.

A. Acceptance of Liability

The named potentially liable operator is the responsible operator within the meaning of the Black Lung Benefits Act.

B. Controversion of Liability

Indicate whether the named potentially liable operator accepts or denies the assertions that follows. 

Acceptance of these assertions is not necessarily an acceptance of liability. You may still contest your liability on any other available grounds.

Accepts Denies

The operator was an operator for any period after 6/30/73.

This operator employed the miner as a miner for a cumulative period of not less than one year.

The miner was exposed to coal mine dust while working for this operator.

The miner's employment with this operator included at least one working day after December 31, 1969.

This operator or its insurer is financially capable of assuming liability for the payment of benefits.

Time period for submission of evidence. Within 90 days of the date on which you received the Notice of Claim, you may submit documentary evidence 

in support of your positions asserted in Section B. For any of the assertions you denied, you must submit all relevant documentary evidence within this 

90-day period. The time period may be extended for good cause shown if an extension request is filed with the district director prior to expiration of the 90 

days period. You must include a statement of reasons why you need additional time with your extension request.

Two Filing Options: 

1. To file electronically, submit completed form to the COAL Mine Portal: 

https://coalmine.dol.gov

 

2. To file by mail, submit completed form to: 

OWCP/DCMWC/CMR Correspondence 

PO Box 8307 

London, KY 40742-8307 

For Further Information call TOLL FREE: 1-800-347-2502 

 

CASE ID:
Form CM-2970a 

Rev. Oct. 2023

Privacy Act Statement 

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) the Black Lung Benefits Act (BLBA) (30 U.S.C. 

901 et seq.), as amended, is administered by the Office of Workers' Compensation Programs (OWCP) of the U.S. Department of Labor, which receives 

and maintains personal information, relative to this application, on claimants and their immediate families; (2) information obtained by OWCP will be used 

to determine eligibility for benefits payable under the BLBA; (3) information may be given to other government agencies, coal mine operators potentially 

liable for payment of the claim or to the insurance carrier or other entity which secured the operator's compensation liability, contractors providing 

automated data processing services to the Department of Labor; and representatives of the parties to the claim; (4) information may be given to 

physicians or other medical service providers for use in providing treatment, making evaluations and for other purposes relating to the medical 

management of the claim; (5) information may be given to the Department of Labor's Office of Administrative Law Judges, or other person, board or 

organization, which is authorized or required to render decisions with respect to the claim or other matters arising in connection with the claim; (6) 

information may be given to Federal, state or local agencies for law enforcement purposes, to obtain information relevant to a decision under the BLBA, to 

determine whether benefits are being or have been paid properly, and where appropriate, to pursue administrative offset and/or debt collection actions 

required or permitted by law; (7) disclosure of the claimant's or deceased miner's Social Security Number (SSN) or tax identifying number (TIN) on this 

form is voluntary, and the SSN and/or TIN and other information maintained by the OWCP may be used for identification and for other purposes 

authorized by law; (8) failure to disclose all requested information, may delay the processing of this claim or the payment of benefits, or may result in an 

unfavorable decision or reduced level of benefits; and (9) this information is included in a System of Records, DOL/OWCP-2 published at 81 Federal 

Register 25765, 25858 (April 29, 2016) or as updated and republished. 

Public Burden Statement 

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, 

searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. Send comments 

regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department 

of Labor, Division of Coal Mine Workers' Compensation, 200 Constitution Avenue, N.W., Suite C3520-DCMWC, Washington, D.C. 20210. Note: Persons 

are not required to respond to this collection of information unless it displays a currently valid OMB control number. (DO NOT SEND THE COMPLETED 

FORM TO THIS OFFICE.) 

Notice 

If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from OWCP 

in the form of communication assistance, accommodation, and modification to aid you in the claims process. For example, we will provide you with copies 

of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for 

the limitations of your disability. Please contact our office or the claims examiner to ask about this assistance. 

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Form CM-2970a 

Rev. Oct. 2023

C. Additional Information

Please answer the questions below. If the space provided for any response is inadequate, please continue your response on a blank sheet of paper and 

attach it to the form. If you are unable to respond to these questions within the 30-day period for accepting or denying the assertions set forth in Section 

B above (i.e. within 30 days of receipt of the Notice of Claim), you should return this form in compliance with the 30-day time limitation and provide the 

information requested in this section within 90 days of your receipt of the Notice of Claim.

1. The miner was employed by the named potentially liable operator (list all periods of employment):

From: To:

Miner's Job Classification(s)/ 

Type(s) of Work Performed

Name and Location of 

Mine or Facility 

(County and State)

Time Performed 

(Beginning and Ending Dates)

2. Our records indicate that the potentially liable operator is insured as indicated in the header of page 1. If this information is 

incorrect, please complete information below.

Insurance Carrier(s) Policy Number Dates of Coverage

3. Is the named potentially liable operator affiliated in any way with any of the other firms identified in the Notice of

Claim as potentially liable operators? Yes No If yes, please explain the nature of the relationship.

4. Has the named potentially responsible operator transferred or sold its mine, mines, or coal mining business, or 

substantially all of the assets thereof, to another person or business organization? Yes No If yes, please

explain the details of the transaction(s), including the name(s) of the person(s) or organization(s) acquiring the property.

5. Please set forth any additional facts regarding potential liability you would like to have considered.

Name and Address of Firm Completing Form Name of Person Completing Form

Title

Signature Date

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