Get Dol Cm-911 2022-2026

Filling out the DOL CM-911 form online is an essential step for miners seeking benefits under the Black Lung Benefits Act. This comprehensive guide provides clear, step-by-step instructions to assist users in completing the form accurately and efficiently.

Follow the steps to fill out the DOL CM-911 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the miner's full name in the designated field; ensure this is the legal name used for identification purposes.
3. Input the miner's Social Security Number in the required format. Note that providing this number is voluntary, but it may assist in processing the claim.
4. Fill in the miner's date of birth, specifying the month, day, and year, which helps establish the miner's eligibility.
5. Indicate the highest grade of education completed by the miner. This information can be relevant for determining the miner's background.
6. Answer whether the miner or someone on their behalf has previously filed a claim for Federal Black Lung benefits. Indicate 'Yes' or 'No' as appropriate.
7. If the answer to the previous question is 'Yes,' provide details about the decision made regarding that claim in the remarks section.
8. State whether the miner is currently employed in or around coal mines. Depending on the answer, you may be prompted to provide additional information.
9. Document the date the miner stopped working in or around coal mines and the state where this occurred. This includes noting the last day of coal mine employment.
10. Describe the reasons for stopping work in the coal mines or a coal preparation facility, including any transfers to lighter duties.
11. Specify the total number of years the miner has worked in coal mines or related facilities to assess their experience.
12. Provide a brief description of any disabilities believed to be linked to pneumoconiosis or other respiratory conditions resulting from coal mine employment.
13. Complete the section regarding any state or Federal Workers’ Compensation claims related to the miner's disability, providing as much detail as possible.
14. List the names and addresses of employers from the previous calendar year, along with earnings information and the duration of employment.
15. Indicate dependent information, including marital status and details regarding any children, addressing their ages and circumstances.
16. In the remarks section, provide any additional information necessary regarding the claims, circumstances, or any follow-up required.
17. Confirm the understanding of the importance of promptly reporting any changes that could affect the benefits claimed.
18. Finalize the form by signing it, including the date and the miner's mailing address, and optionally provide contact details such as telephone number and email address.
19. After completing the form, save changes, then you can download, print, or share the completed document as necessary.

Complete your DOL CM-911 form online today to ensure a smoother claims process.