DOL-ESA Forms. cm-911 2026

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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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2022	4.8 Satisfied (35 Votes)
1998	4 Satisfied (54 Votes)

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Who qualifies for black lung?

To be eligible for this benefit program, you must be one of the following: A coal miner, who suffers from an illness caused by pneumoconiosis (black lung disease), or. A widow or widower whose spouse died due to a work-related illness caused by Pneumoconiosis.

What are the symptoms of black lung disease?

In early stages, the most common symptoms are cough, shortness of breath and chest tightness. Sometime the coughing may bring up black sputum (mucus). These symptoms may initially occur after strenuous activity, but as the disease progresses, they may become present at rest as well.

How do I fill out a Ca 2 form?

15:25 21:54 How to Fill In a CA 2 - YouTube YouTube Start of suggested clip End of suggested clip Question is being asked here in a separate narrative statement attached to the form the employeeMoreQuestion is being asked here in a separate narrative statement attached to the form the employee must submit the following information a detailed history of disease or illness from date.

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Do you pay taxes on Black Lung Benefits?

Black lung benefit trusts are subject to excise taxes on: \u2022 certain acts of self-dealing, IRC Section 4951 \u2022 taxable expenditures, IRC Section 4952 \u2022 excess contributions to these trusts, IRC Section 4953. self-dealing and taxable expenditures per Treas.

Is silicosis considered a disability?

Filing for Social Security Disability with a Pneumoconiosis Diagnosis. Pneumoconiosis is recognized by the Social Security Administration as a disabling condition, and is listed under Respiratory System in the Adult Listings of Impairments.

Is black lung considered a disability?

The Federal Coal Mine Health and Safety Act of 1969 provided benefits to coal miners totally disabled by pneumoconiosis--commonly called "black lung" --and to dependents of miners who had died from the disease or were totally disabled from it at death.

Who pays for black lung benefits?

Today, roughly 75 percent of all Black Lung Benefit Act claims are paid from the Trust Fund. The Black Lung Disability Trust Fund is financed primarily by a tax on coal produced and sold domestically. The tax was first established in 1978 at $0.50 per ton on underground coal, and $0.25 per ton on surface coal.

Does Black Lung benefits affect Social Security?

Reduction of social security disability benefits has occurred in less than 5 percent of allowed miners' black lung claims. In most instances where reduction is necessary, only a partial reduction rather than total offset of the social security disability benefit is required.

DOL-ESA Forms. cm-911 2026

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