Get Dol Cm-911 1998-2026

The DOL CM-911 form is essential for miners seeking benefits under the Black Lung Benefits Act. This guide will walk you through the process of filling out this important document online, ensuring that you have all the necessary information at hand.

Follow the steps to complete your DOL CM-911 form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide the miner's full name (first, middle, last) and date of birth (month, day, year) in the appropriate fields.
3. Enter the miner's Social Security Number in the designated area. Note that disclosing this information is voluntary.
4. Indicate the highest grade completed in school by the miner in the corresponding field.
5. Answer whether a claim for Federal Black Lung benefits has been filed before. If 'yes', provide details in the remarks section.
6. State whether the miner is currently working in or around coal mines and provide information regarding the employment status.
7. Detail the miner's work history, including years of experience and past employers, using Form CM-911a if necessary.
8. Describe any disabilities believed to be due to pneumoconiosis or respiratory diseases arising from coal mining.
9. If applicable, provide details regarding any workers' compensation claims, including the agency involved and payment information.
10. Complete sections regarding marital status and any support payments. Ensure to answer questions about previous marriages.
11. List any unmarried children who may be eligible for benefits and provide their details in the relevant fields.
12. Agree to notify the Department of Labor of any events that may affect the benefits, such as changes in employment status.
13. Complete the authorization sections to allow the Department of Labor to access necessary health information.
14. Sign the form, certifying the accuracy of the information provided. Include the date and mailing address.
15. Review the completed form for accuracy and completeness before saving your changes, downloading, printing, or sharing it.

Start filling out your DOL CM-911 form online today to ensure you receive the benefits you may be entitled to.