Skip to page content
Office of Workers' Compensation Programs
Bookmark and Share

Division of Coal Mine Workers' Compensation (DCMWC)

On This Page

DCMWC Forms

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 DCMWCs 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 our central mailroom at the following address:

U.S. Department of Labor
OWCP/DCMWC/CMR Correspondence
P.O. Box 8307
London, KY 40742-8307

Form-Fill Option

Forms noted with an asterisk (*) may be electronically filled. 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.

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

CM-921

Instructions For Completion of Form CM-921

CM-929

Report of Changes That May Affect Your Black Lung Benefits

CM-929P

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)

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

CM-988*

Medical History and Examination for Coal Mine Workers' Pneumoconiosis

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

CM-2970a*

Operator Response to Notice of Claim

OWCP-1*

Agreement and Undertaking

OWCP-20*

Overpayment Recovery Questionnaire

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