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OWCP’s Division of Coal Mine Workers' Compensation has made a variety of forms available online. These forms are only available in PDF format. In order to view and/or print PDF documents you must have a PDF viewer. It is highly recommended that you have the most current version (click on Adobe Acrobat Reader to download the current version) available on your workstation.

The forms in the list below may be completed manually via the print form option or electronically via the electronic fill/submit option:

Print Form Option

Most of DCMWC’s forms are available online to print and to manually fill and submit. Simply click on the appropriate form and print it using the [Print] button provided near the top of the form. Write or type the required information on the hardcopy and authorize the form, if applicable, with a hand-written signature. Then mail the completed form to the DCMWC office you normally send to for this process. Please click here for a list of district offices and their addresses.

Form-Fill Option

Simply click on the appropriate form, fill out the form using your computer keyboard and the <TAB> key or your mouse to navigate between form fields. Print the form (use the Print button on or near the top of the form), authorize the form (if applicable provide hand-written signature) and mail the completed form to the DCMWC office you normally send to for this process.

Electronic Fill/Submit Option

Select DCMWC forms, noted with an asterisk (*) on the list of forms below, may be electronically filled and submitted to OWCP/DCMWC. To do so, you must have Adobe Reader 6.x installed on your PC.

To electronically submit a DCMWC form, follow these simple steps:

1. Obtain an electronic signature from IdenTrust Inc. Upon opening the form, if you don't already have a digital signature on your PC, you will be directed to the IdenTrust Inc. website to obtain an electronic signature. The entire process of obtaining the electronic signature will take 5-10 business days. (You only have to do this one time. Thereafter, you will use the same signature.)
   Note: Adobe 6.x is required to apply a digital signature
   

2. Fill out the form completely. It is recommended that you print the form prior to submitting, and keep the hardcopy for your records. To do so, use the [Print] button provided near the top of the form.

3. Click on the [Submit] button near the top of the form. A message will appear noting that the form has been received and will provide an identification number. It is recommended that you record the ID number on your hardcopy.

4. If you have questions about filling/submitting these forms or need other forms assistance, you can send DCMWC a question via e-mail by clicking DCMWC-FormsAssistance. DCMWC will respond to your question via e-mail.

NOTE: When printing these files please remember to use the Adobe Acrobat Reader print icon or the [Print] button on the form, itself, and NOT your browser's print icon on the browser toolbar.

	Black Lung Forms
CM-623,	Representative Payee Report
CM-623S,	Representative Payee Report
CM-787,	Physician's/Medical Officer's Statement
CM-893,	Certificate of Medical Necessity
CM-908,	Notice of Termination, Suspension, Reduction or Increase in Benefit Payments
CM-910,	Request To Be Selected As Payee
CM-911,	Miner's Claim For Benefits Under The Black Lung Benefits Act
CM-911a,	Employment History
CM-912,	Survivor's Form For Benefits Under The Black Lung Benefits Act
CM-913*,	Description Of Coal Mine Work and Other Employment On-line submission now available
CM-918,	Coal Mine Employment Affidavit
CM-921,	Instructions For Completion of Form CM-921
CM-929,	Report of Changes That May Affect Your Black Lung Benefits
CM-933,	Roentgenographic Interpretation
CM-933b,	Roentgenographic Quality Rereading
CM-936*,	Authorization For Release Of Medical Information (Black Lung Benefits) On-line submission now available
CM-972,	Application for Approval of a Representative's Fee in a Black Lung Claim Proceeding Conducted by The U.S. Department of Labor
CM-981*,	Certification by School Official On-line submission now available
CM-988,	Medical History and Examination for Coal Mine Workers' Pneumoconiosis
CM-1093,	Affidavit of Deceased Miner's Condition
CM-1159,	Report of Arterial Blood Gas Study
CM-2907,	Report of Ventilatory Study
CM-2970*,	Operator Response to Schedule for Submission of Additional Evidence On-line submission now available
CM-2970a*,	Operator Response to Notice of Claim On-line submission now available
OWCP-1,	Agreement and Undertaking
OWCP-915,	Claim For Medical Reimbursement Form OWCP-915 replaces CA-915
OWCP-957,	Medical Travel Refund Request
OWCP-1168,	Provider Enrollment Form
OWCP-1500,	Health Insurance Claim Form