Instructions For Completion of Form CM-921

• Legal Form Number: CM-921
• Issuer: Office of Workers' Compensation Programs - Division of Coal Mine Workers' Compensation
• Section: U.S. Department of Labor

U.S DEPARTMENT OF LABOR

Office of Workers' Compensat ion Programs

Division of Coal Mine Workers' Compensation

Form CM-921

Revised Sept. 2019

Previous version usable

OMB No. 1240-0048

Expires: 11/30/2026

Instructions For Completion of Form CM-921

Reports of Coverage for Policies of Insurance Under the Black Lung Benefits Act (the Act), 30

U.S.C. 901-944.

Under the Act, each carrier or State fund providing coverage to operators under the provisions of the Act

is required (20 CFR 726.208 - .213) to report to the Office of Workers' Compensation Programs each

policy and endorsement issued by it to an operator who carries on coal mining operations in a named

State or States. The report must be made on Form CM-921 and filed with the Office of Workers'

Compensation Programs. A sample report (Form CM-921) is included for reference. Each carrier should

complete the form at the beginning of a new coverage period and submit it to the U.S. Department of

Labor, Office of Workers' Compensation Programs, Division of Coal Mine Workers’ Compensation, 200

Constitution Avenue, N.W., Suite C3520-DCMWC, Washington, D.C. 20210, or file electronically by

submitting to DCMWC-public@dol.gov.

IMPORTANT: Carriers are NOT REQUIRED to submit this form if the insured coal mining operations are

conducted in a state that reports all workers’ compensation insurance coverage to the National Council

on Compensation Insurance (NCCI).

Cancellation of a contract or policy of insurance issued under the authority of the Act shall not become

effective otherwise than as provided by the provisions under 33 U.S.C. 936(b), as incorporated by 30

U.S.C. 932(a), which requires that the carrier or State fund must submit a notice to the Office of

Workers' Compensation Programs and to the operator of the proposed cancellation 30 days before

such cancellation is intended to be effective.

1. NAME OF EMPLOYER - The correct name of the coal mine operator must be written in full, as well

as the trade name, if the business is conducted under a trade name; if partnership, the correct

partnership name must be shown.

a. A separate card report for each operator covered shall be submitted. The name of only one operator

shall appear on each report.