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. Follow these instructions to download PDF files and open them in Adobe Acrobat Reader.
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 our central mailroom at the following address:
U.S. Department of Labor OWCP/DCMWC
P.O. Box 8307
London, KY 40742-8307
IMPORTANT: We are working to have our forms and business reply envelopes updated with the London, KY addresses. Until that is complete, the mailroom currently listed in San Antonio, TX will be forwarding all mail to London, KY. To reduce mail processing delays, please use the London, KY address for mailing, even if the address on the form is San Antonio, TX.
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.
Form | Title |
|---|---|
| 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* CM-911-Large Print* | Miner's Claim For Benefits Under The Black Lung Benefits Act Large Print Version - Miner's Claim For Benefits Under The Black Lung Benefits Act |
| CM-911a* CM-911a-Large Print* | Employment History Large Print Version - Employment History |
| CM-912* CM-912-Large Print* | Survivor's Form For Benefits Under The Black Lung Benefits Act Large Print Version - Survivor's Form For Benefits Under The Black Lung Benefits Act |
| 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-2017* | Application or Renewal of Self-Insurance Authority Instructions for Applying or Renewing Self-Insurance |
| CM-2017a* | Financial Summary for Self-Insured Operators |
| CM-2017b* | Report of Claims Information for Self-Insured Operators |
| 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-04 | Uniform Billing Form |
| OWCP-20* | Overpayment Recovery Questionnaire |
| OWCP-915* | Claim For Medical Reimbursement Form OWCP-915 replaces CA-915 |
| OWCP-957B* | Medical Travel Refund Request – Expenses |
| OWCP-1168 | Provider Enrollment Form |
| OWCP-1500* | Health Insurance Claim Form |