Division of Coal Mine Workers' Compensation (DCMWC)

The steps outlined here are intended as a "quick-start" guide for active or retired miners. More detailed information about filing a claim as an active or retired miner is available on our website. Should you have any questions, please contact the District Office that has jurisdiction over your claim.

Step 1: Complete the application form entitled, "Miner's Claim for Benefits under the Black Lung Act" (form CM-911)

Step 2: Complete the form entitled, "Employment History" (form CM-911a)

Step 3: Review SSA-581 instructions and complete two copies of the form entitled, "Authorization to Obtain Earnings Data from the Social Security Administration" (SSA-581)

Step 4: Review "Selection of Examining Provider" instructions and complete the "Selection of Examining Provider" form. Please note, you should select a provider in your home state or a contiguous state. A list of approved providers is available.