13. How many total years did you work in coal mine employment? 

12. In what state of the United States were you working when your coal mine employment ended, or what state are you currently engaged in coal mine 

employment? 

11. Are you still engaged in coal mine employment (in or around coal mines or a coal preparation facility in the extraction, transportation, or preparation of coal, 

or in coal mine construction or maintenance in or around a coal mine)? 

10. Decision made (If more than one claim has been filed, identify, and 

show the disposition of each in Item 23, “Remarks,”)

8. Highest grade miner completed in school

5. Miner’s Email Address

3. Mailing Address (Number, Street, Apt. No., P.O. Box or Rural Route) 4. City, State, & Zip Code

U.S. Department of Labor 

Office of Workers' Compensation Programs

Miner’s Claim for Benefits Under 

The Black Lung Benefits Act

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

for any benefits that may be payable under the Act.

OMB No. 1240-0038 

Expires: 10/31/2026

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

Disclosure of your Social Security Number is voluntary; the failure to disclose your Social Security number will not result in the denial of 

any right, benefit, or privilege to which an individual may be entitled. The collection of the other information on this form is authorized by 

law (30 U.S.C. 901, et. seq.). This information is required to obtain a benefit. The Department of Labor conducts computer matches 

with the Social Security Administration. Any information provided by applicants or recipients of financial assistance or payments under 

Federal benefit programs may be subject to verification through computer matches that the Department of Labor conducts with these 

agencies.

(FOR DOL USE)

DISABILITY: 

NOTE: If available evidence is insufficient 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 the physician.

14. 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 last coal mine employment job in the coal mines are you physically unable to perform as a result of your 

disability? 

CM-911 Rev. (10-2023)

7. Miner’s Date of birth (Month, day, year)

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

benefits before? If yes, answer question 10.

Allowed

Withdrawn

Denied

Pending

Yes No

Yes No If no, answer a. 

1. Miner's Full Name (First, Middle, Last) 2. Miner's Social Security Number

6. Telephone Number (Include area code)

a. When did your coal mine employment end? Provide month, day, and year of last coal mine employment:
DEPENDENTS:

WORKERS’ COMPENSATION: 

NOTE: The amount of state or federal workers’ compensation and/or occupational disease benefits you receive based on your disability due to coal workers' 

pneumoconiosis will be subtracted from your benefits under Part C of the Black Lung Benefits Act. This does not apply to benefits under the Longshore and 

Harbor Workers’ Compensation Act (LHWCA) or Social Security Disability Insurance benefits for pneumoconiosis.

15. Are you currently working? Yes No If yes, answer a.

b. Approximate date of filing: c. Claim No. (If known):

Approximate Annual 

Earnings

Work Began 

Month/Year

Work Ended 

Month/Year Name and Address of Employer

a. Date of marriage (if "Yes'' Complete items a-f) 

(if "No" go to item 18). 17. Are you currently married? Yes No

b. Your spouse’s first and last name prior to marriage: 

Social Security Number:

e. Are you under a court order to make support payments to your current spouse?

Yes No (If “Yes,” attach a copy of the order.)

f. Do you make regular support payments to your current spouse?

Yes No (If “Yes,” indicate amount.)

(week, month, other)

$ per

18. Have you ever been previously married? Yes No (If “Yes,” answer a through f.)

a. Full Name of your previous spouse:

Social Security Number:

b. Date married: (MM/DD/YYYY)

If prior marriage ended by divorce and you were married for 10 years before the divorce action, answer questions 19 and 20.

20. Do you make substantial monetary contributions to a divorced spouse?

per

(If “Yes,” indicate amount)

(week, month, other)

$

Yes No

19. Are you under a court order to make support payments to a divorced spouse?

Yes No (If “Yes,” attach a copy of the order).

CURRENT EMPLOYMENT AND WAGES: 

NOTE: The amount of your earnings, either as an employee or from self-employment, will help us determine the correct payment of black lung benefits to which 

you may be entitled. This information is required by the 1981 Amendments to the Black Lung Benefits Act.

c. Spouse's birth date:

(If “No,” answer items e and f.)

d. Do you reside with your spouse?

Yes No

Page 2 CM-911 Rev. (10/2023)

d. How marriage ended: (death, divorce) e. Date marriage ended: (MM/DD/YYYY) f. Place marriage ended: (City, State)

a. Enter the names and addresses of all persons, companies, or government agencies for which you worked during the previous calendar year. If selfemployed, so indicate.

16. Have you filed a workers’ compensation claim under any state or federal law on account of your disability, due to coal workers’ pneumoconiosis?

Yes No (If “Yes,” complete items a through k.)

k. Are you currently receiving medical benefits as part of your workers’ compensation benefits? Yes No

a. With what state or federal agency was the claim filed?

d. Decision made: Approved Denied Pending

(If approved, please provide a complete copy of your workers’ 

compensation award.) 

f. Amount of payment:

per week

per

Weekly: $

Other: $

h. Did you pay any attorney fees or legal fees in securing your 

workers’ compensation award?

Yes No

e. Employer against whom your workers’ compensation claim was filed?

g. Date payments began:

Date payments ended:

i. If you received a lump sum payment based on your workers’ compensation claim, 

please indicate the following:

Period covered: From: To:

Amount: $

j. Have you ever received medical benefits as part of your workers’ compensation benefits? Yes No

c. Place married: (City & State)
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

Biological Adopted

Stepchild Other

DEPENDENTS continued:

21. Please list all your unmarried children who fit into one of the following categories: currently under the age of 18; age 18 to 23 and attending full-time 

school; and age 18 or older and disabled. If you do not have any children that fit these categories, please skip to question 22. Use “remarks” space in item 23 if 

the space below is insufficient. 

IF THERE ARE NO CHILDREN WHO FIT THESE CATEGORIES, SKIP TO 22.

Full Name of Child: Social Security 

Number

Date of Birth 

MM/DD/YYYY Eligibility Category Child’s relationship to you 

Last, First, Middle: Under age 18 Full-Time Student

Disabled 

Biological Adopted

Stepchild Other

If any child named above does not live with you, enter the name and address of the person or organziation with whom the child lives. Please list this 

information under item 23 “remarks.” 

IMPORTANT NOTICE 

22. The events listed below may affect your eligibility or the amount of your Federal Black Lung benefits: 

Your condition improves; or 

You become entitled to state workers’ compensation or occupational disease payments due to disability on account of pneumoconiosis; or 

The amount of any of the benefits described above to which you are entitled changes; or 

You work in or around coal mines or any other employment, including self-employment. 

 The events listed below relating to your dependents may also affect the amount of your Federal Black Lung benefits: 

A dependent marries, divorces, dies, or is adopted by someone else; or 

A child age 18-23 stops attending school, or in the case of a disabled child 18 or older, the disabling condition improves. 

It is IMPORTANT that you report PROMPTLY any of the above events that occur. Failure to report events promptly could result in an overpayment requiring 

repayment.

Do you agree to notify the Department of Labor if any of the above events occur?

Page 3 CM-911 Rev. (10/2023)

Yes No

23. Remarks. (You may use this space for explanations. If you need more space, attach a separate sheet.)

SIGNATURE OF MINER 

I hereby certify that the information given by me on and in connection with this form is true and correct to the best of my knowledge and belief. I am also fully 

aware that any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or payment under this 

title shall be guilty of a misdemeanor under 30 USC 941 and, on conviction, subject to a fine of not more than $1,000.00, or by imprisonment for not more than 

one year, or both. I authorize any physician, hospital, agency, employer or other organization (including the Social Security Administration) to disclose any 

medical records, or other information to the Department of Labor, Office of Workers’ Compensation Programs. Furthermore, I authorize the Department of 

Labor, Office of Workers’ Compensation Programs to disclose any medical or other information about the decision in your Black Lung Benefits claim to the 

Workers’ Compensation, Unemployment Compensation, or Disability Insurance agency of my State to use in connection with any claim with another agency.

Last, First, Middle: Under age 18 Full-Time Student

Disabled 

Last, First, Middle: Under age 18 Full-Time Student

Disabled 

Last, First, Middle: Under age 18 Full-Time Student

Disabled 

Biological Adopted

Stepchild Other

24. Signature of Claimant (First, Middle, Last) 25. Date (Month, Day, Year)

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the 

applicant must sign below, giving their full address.

26. Signature of witness 27. Signature of witness

28. Witness Address (Number, street, city, state & zip code) 29. Witness Address (Number, street, city, state & zip code)

Biological Adopted

Stepchild Other
PRIVACY ACT NOTICE 

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 for this collection of information is estimated to average 45 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, Room C-3520, 200 Constitution Avenue, NW, Washington, DC 20210. 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 staff to ask for assistance.

Page 4 CM-911 Rev. (10/2023)

TWO FILING OPTIONS: 

1. To file electronically, submit completed form and accompanying documentation to the C.O.A.L. Mine Portal: 

https://coalmine.dol.gov

2. To file by mail submit completed form and accompanying documentation to: 

U.S. Department of Labor OWCP/DCMWC 

Central Mail Room 

PO Box 8307 

London, KY 40742-8307 

 

For further information call TOLL FREE: 1-800-347-2502