DOL-ESA Forms. cm-911 2026

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54 votes

The document is a claim form for benefits under the Black Lung Benefits Act, administered by the U.S. Department of Labor. It allows miners to apply for benefits due to disabilities resulting from coal workers' pneumoconiosis or other respiratory diseases related to coal mining. The form requires personal information, employment history, details about any previous claims, and information regarding dependents. It emphasizes the importance of providing accurate information and notifying the Department of Labor about any changes that may affect benefit eligibility.

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Click ‘Get Form’ to open the DOL-ESA Forms. cm-911 in the editor.
Begin by entering the miner's full name, date of birth, and Social Security Number in the designated fields. Ensure accuracy as this information is crucial for processing your claim.
Proceed to indicate whether you have previously filed a claim for Federal Black Lung benefits. Select 'Yes' or 'No' and provide any necessary details if applicable.
Fill out your employment history, including names and addresses of employers from the previous calendar year. This section helps determine your eligibility for benefits.
In the disability section, describe any respiratory issues related to coal mine employment. Be specific about how these conditions affect your work capabilities.
Complete the marital status section if applicable, providing details about your spouse and any support payments required by court order.
Finally, review all entered information for accuracy before signing and dating the form at the bottom. If signed by mark (X), ensure two witnesses sign as well.

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Versions	Form popularity	Fillable & printable
2022	4.8 Satisfied (35 Votes)
1998	4 Satisfied (54 Votes)

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