How to File for a Black Lung Benefit Claim
Note: All forms are given in .pdf format which can be read by downloading the Adobe Acrobat Reader.
First, let’s get you all the forms you will need. Yes, you will need all of these so go ahead and fill them out. Here is a list of forms you will need to have and/or fill out. Just click on the red links to get each form.
Forms Needed:
1) Miner’s Claim for Benefits Under the Black Lung Act (Form CM-911)
Use form CM-912 for widows or survivors of miners
2)Employment History (Form CM-911a)
3) Medical Development Information (Form CM-934)
If you were never treated for lungs or heart, write “No Sources” and submit it. You may not need to fill out this form, but if you do, it will be provided for you.
4) Authorization for Release of Medical Information (Form CM-936)
NOTE: Most people will only need to complete only Questions 1 through 8.
5) Consent for IRS to Release Tax Information (Form CM-1087)
You may be asked later to fill this one out. If so, it will be provided for you.
Certificates and Documentation Needed:
1) Marriage Certificate: Miners should submit a marriage certificate if currently married. If a previous marriage of 10 or more years ended in divorce, and a court ordered payment of alimony or the miner is paying support to the divorced spouse, submit a marriage certificate and a divorce decree of that marriage. Widows should submit a marriage certificate for marriage to the miner. Marriage Certificates must be either originals or certified copies (with a seal) from the courthouse. All original documents will be photocopied and returned to you as soon as possible.
2) Birth Certificates for Dependent Children Listed on the Application: Birth Certificates must be either originals or certified copies (with a seal) from the courthouse. All original documents will be photocopied and returned to you as soon as possible.
3) State Workers Compensation Awards Listed On the Application: State awards for occupational pneumoconiosis (Black Lung) or silicosis
Proof of Coal Mine Employment:
It is necessary that all coal mine employment be proven to the extent possible. Possible sources to document this employment (listed in order of preference) include:
1) Work Record from Employer(s) with dates of employment and type of work
2) Social Security Earnings Record detailing employers and amount of yearly earnings. Records from 1978 to the present may be obtained from your local Social Security Office at no charge. There is a charge for records prior to 1978. If you are unable to obtain evidence prior to 1978, the Department of Labor will obtain those records for you.
3) W-2 Forms or Pay Stubs with year-to-date earnings.
4) UMWA Pension Approval and Calculation Worksheet.
For Widows and Survivors, additional certificates and documentation are required:
1) Survivor's Form For Benefits Under The Black Lung Benefits Act (Form CM-912)
2) Certified Death Certificate
3) Autopsy report (if applicable): Complete autopsy report with microscopic findings.
Important: If you are unable to provide any of the required documents, or will have a delay in providing them, please write up a brief explanation to be sent to the Department of Labor.
***********************************
Overview of What to Do:
The Black Lung Benefits Act provides monthly benefits to coal miners who are totally disabled by black lung disease caused by working in the coal mining industry. “Totally disabled” means you are unable to perform the work you did as a coal miner because breathing coal mine dust has permanently impaired your ability to breathe normally. You may also receive additional benefits for family members who are dependent on you and for the cost of your own medical treatment. A coal mining company which employed you (usually the last company that employed you for a year or more) may be required to pay your benefits if it meets certain requirements under the law. Otherwise, the Black Lung Disability Trust Fund will pay your benefits.
The First Step:
The first step in the process of applying or Black Lung benefits is to complete an application form. You will be asked to provide important basic information about yourself and your family. This form is called the “Miner’s Claim for Benefits Under the Black Lung Act” (Form CM-911). You will also complete an “Employment History” (Supplemental Form CM-911a). This form requests information about your work as a miner, the number of years you worked, the names of the coal companies which employed you, and your work outside the coal mining industry. We need this information to determine whether you were a coal miner and whether a specific coal mining company will pay your benefits. A representative from the U.S. Department of Labor (Division of Coal Mine Worker’s Compensation) or the Social Security Administration can assist you in completing the application forms.
Based on the information in your benefits application and Employment History form, you may be asked to provide additional information, including copies of official documents.
This information may include:
Copies of marriage certificates
Children’s birth certificates
Death certificates
Proof of enrollment in schools for dependent children
etc.
This information is necessary to establish basic facts about your entitlement to benefits or the entitlement of members of your family.
The Next Step:
After your benefits application has started to be processed, you will be contacted to schedule a complete pulmonary evaluation. A “pulmonary evaluation” is a medical examination to determine whether you are totally disabled by black lung disease. The Department of Labor is required by law to offer you a free examination to prove that you may be entitled to black lung benefits. You will be provided with a list of physicians who can perform this examination. All of these physicians will be located in your state or a bordering state and you will be asked which physician you wish to use.
The examination consists of:
A physical examination by a physician
A chest X-ray
A pulmonary function test
An arterial blood gas test (unless medically contraindicated)
If you refuse to be examined, your claim may be denied without any further consideration of your entitlement to benefits. You also have the right to have the results of this examination sent to your personal physician.
After the results of your pulmonary examination are received by the Department of Labor, a preliminary review of those results will be performed to determine whether they support an award or denial of your claim. This review is not final. You will receive a letter explaining the results of the examination and the reasons for the Department of Labor’s opinion about your entitlement. The letter is called the “Schedule for the Submission of Additional Evidence.” The “Schedule” will inform you about your opportunity to submit additional evidence, your right to obtain medical evidence from a physician of your own choosing, and the time limits for submitting evidence. If the Department of Labor finds that a coal company is liable for your claim, that company has a right to have you examined by a physician of its choice. If you refuse to be examined, your claim may be denied without any further consideration of your entitlement of benefits.
The most important part of applying for Black Lung benefits is obtaining medical evidence about your physical condition.
The Black Lung benefits program has limitations on the amount of medical evidence which you and the coal company may give the Department of Labor for determining whether you are entitled to benefits.
Because this is a complex process, you are encouraged to get advice from an attorney or other qualified representative before submitting any additional medical evidence to the Department of Labor. Ordinarily, attorney’s fees which must be paid if your claim is approved will be paid by the coal company liable for your claim or the Black Lung Disability Trust Fund, though certain situations exist in which you may be liable for payment of attorney’s fees. You are not liable for any attorney’s fees if your claim is denied.
When the Department of Labor has received all of the evidence in your claim, they will decide whether your claim has been approved or denied. In some cases, you may be asked to attend an “informal conference” to discuss your claim before the decision is made. If an “informal conference” is necessary, you will be informed, in writing, of your rights and obligations when the conference is scheduled. After your claim has been reviewed and also all of the evidence (and the results of the conference, if one is held), you will be issued a “Proposed Decision and Order.” This decision will approve or deny your claim and explain the reasons for the Department of Labor’s decision. You will also be informed (and the coal company if one is liable for your claim) of the options for challenging the decision and the time limits for taking any further action. These options include asking the Department of Labor to reconsider its decision or asking for a hearing before an administrative law judge.
If you have any question about the benefits application process, you can get answers. For people of McDowell County, you should contact the district office in Charleston, WV.
U.S. Department of Labor
ESA/OWCP/DCMWC
Charleston Federal Center - Suite 110
500 Quarrier Street
Charleston, West Virginia 25301
Commercial: (304) 347-7100
Toll-Free (800) 347-3749
Outside of McDowell County, and other jurisdictions, you may find out which agency you need to contact by going to the website of the Dept. of Labor's Division of Coal Mine Workers' Compensation Home Page.
Note: All forms are given in .pdf format which can be read by downloading the Adobe Acrobat Reader.
First, let’s get you all the forms you will need. Yes, you will need all of these so go ahead and fill them out. Here is a list of forms you will need to have and/or fill out. Just click on the red links to get each form.
Forms Needed:
1) Miner’s Claim for Benefits Under the Black Lung Act (Form CM-911)
Use form CM-912 for widows or survivors of miners
2)Employment History (Form CM-911a)
3) Medical Development Information (Form CM-934)
If you were never treated for lungs or heart, write “No Sources” and submit it. You may not need to fill out this form, but if you do, it will be provided for you.
4) Authorization for Release of Medical Information (Form CM-936)
NOTE: Most people will only need to complete only Questions 1 through 8.
5) Consent for IRS to Release Tax Information (Form CM-1087)
You may be asked later to fill this one out. If so, it will be provided for you.
Certificates and Documentation Needed:
1) Marriage Certificate: Miners should submit a marriage certificate if currently married. If a previous marriage of 10 or more years ended in divorce, and a court ordered payment of alimony or the miner is paying support to the divorced spouse, submit a marriage certificate and a divorce decree of that marriage. Widows should submit a marriage certificate for marriage to the miner. Marriage Certificates must be either originals or certified copies (with a seal) from the courthouse. All original documents will be photocopied and returned to you as soon as possible.
2) Birth Certificates for Dependent Children Listed on the Application: Birth Certificates must be either originals or certified copies (with a seal) from the courthouse. All original documents will be photocopied and returned to you as soon as possible.
3) State Workers Compensation Awards Listed On the Application: State awards for occupational pneumoconiosis (Black Lung) or silicosis
Proof of Coal Mine Employment:
It is necessary that all coal mine employment be proven to the extent possible. Possible sources to document this employment (listed in order of preference) include:
1) Work Record from Employer(s) with dates of employment and type of work
2) Social Security Earnings Record detailing employers and amount of yearly earnings. Records from 1978 to the present may be obtained from your local Social Security Office at no charge. There is a charge for records prior to 1978. If you are unable to obtain evidence prior to 1978, the Department of Labor will obtain those records for you.
3) W-2 Forms or Pay Stubs with year-to-date earnings.
4) UMWA Pension Approval and Calculation Worksheet.
For Widows and Survivors, additional certificates and documentation are required:
1) Survivor's Form For Benefits Under The Black Lung Benefits Act (Form CM-912)
2) Certified Death Certificate
3) Autopsy report (if applicable): Complete autopsy report with microscopic findings.
Important: If you are unable to provide any of the required documents, or will have a delay in providing them, please write up a brief explanation to be sent to the Department of Labor.
***********************************
Overview of What to Do:
The Black Lung Benefits Act provides monthly benefits to coal miners who are totally disabled by black lung disease caused by working in the coal mining industry. “Totally disabled” means you are unable to perform the work you did as a coal miner because breathing coal mine dust has permanently impaired your ability to breathe normally. You may also receive additional benefits for family members who are dependent on you and for the cost of your own medical treatment. A coal mining company which employed you (usually the last company that employed you for a year or more) may be required to pay your benefits if it meets certain requirements under the law. Otherwise, the Black Lung Disability Trust Fund will pay your benefits.
The First Step:
The first step in the process of applying or Black Lung benefits is to complete an application form. You will be asked to provide important basic information about yourself and your family. This form is called the “Miner’s Claim for Benefits Under the Black Lung Act” (Form CM-911). You will also complete an “Employment History” (Supplemental Form CM-911a). This form requests information about your work as a miner, the number of years you worked, the names of the coal companies which employed you, and your work outside the coal mining industry. We need this information to determine whether you were a coal miner and whether a specific coal mining company will pay your benefits. A representative from the U.S. Department of Labor (Division of Coal Mine Worker’s Compensation) or the Social Security Administration can assist you in completing the application forms.
Based on the information in your benefits application and Employment History form, you may be asked to provide additional information, including copies of official documents.
This information may include:
Copies of marriage certificates
Children’s birth certificates
Death certificates
Proof of enrollment in schools for dependent children
etc.
This information is necessary to establish basic facts about your entitlement to benefits or the entitlement of members of your family.
The Next Step:
After your benefits application has started to be processed, you will be contacted to schedule a complete pulmonary evaluation. A “pulmonary evaluation” is a medical examination to determine whether you are totally disabled by black lung disease. The Department of Labor is required by law to offer you a free examination to prove that you may be entitled to black lung benefits. You will be provided with a list of physicians who can perform this examination. All of these physicians will be located in your state or a bordering state and you will be asked which physician you wish to use.
The examination consists of:
A physical examination by a physician
A chest X-ray
A pulmonary function test
An arterial blood gas test (unless medically contraindicated)
If you refuse to be examined, your claim may be denied without any further consideration of your entitlement to benefits. You also have the right to have the results of this examination sent to your personal physician.
After the results of your pulmonary examination are received by the Department of Labor, a preliminary review of those results will be performed to determine whether they support an award or denial of your claim. This review is not final. You will receive a letter explaining the results of the examination and the reasons for the Department of Labor’s opinion about your entitlement. The letter is called the “Schedule for the Submission of Additional Evidence.” The “Schedule” will inform you about your opportunity to submit additional evidence, your right to obtain medical evidence from a physician of your own choosing, and the time limits for submitting evidence. If the Department of Labor finds that a coal company is liable for your claim, that company has a right to have you examined by a physician of its choice. If you refuse to be examined, your claim may be denied without any further consideration of your entitlement of benefits.
The most important part of applying for Black Lung benefits is obtaining medical evidence about your physical condition.
The Black Lung benefits program has limitations on the amount of medical evidence which you and the coal company may give the Department of Labor for determining whether you are entitled to benefits.
Because this is a complex process, you are encouraged to get advice from an attorney or other qualified representative before submitting any additional medical evidence to the Department of Labor. Ordinarily, attorney’s fees which must be paid if your claim is approved will be paid by the coal company liable for your claim or the Black Lung Disability Trust Fund, though certain situations exist in which you may be liable for payment of attorney’s fees. You are not liable for any attorney’s fees if your claim is denied.
When the Department of Labor has received all of the evidence in your claim, they will decide whether your claim has been approved or denied. In some cases, you may be asked to attend an “informal conference” to discuss your claim before the decision is made. If an “informal conference” is necessary, you will be informed, in writing, of your rights and obligations when the conference is scheduled. After your claim has been reviewed and also all of the evidence (and the results of the conference, if one is held), you will be issued a “Proposed Decision and Order.” This decision will approve or deny your claim and explain the reasons for the Department of Labor’s decision. You will also be informed (and the coal company if one is liable for your claim) of the options for challenging the decision and the time limits for taking any further action. These options include asking the Department of Labor to reconsider its decision or asking for a hearing before an administrative law judge.
If you have any question about the benefits application process, you can get answers. For people of McDowell County, you should contact the district office in Charleston, WV.
U.S. Department of Labor
ESA/OWCP/DCMWC
Charleston Federal Center - Suite 110
500 Quarrier Street
Charleston, West Virginia 25301
Commercial: (304) 347-7100
Toll-Free (800) 347-3749
Outside of McDowell County, and other jurisdictions, you may find out which agency you need to contact by going to the website of the Dept. of Labor's Division of Coal Mine Workers' Compensation Home Page.