PDF
Word
This version of the form is not currently in use and is provided for reference only. Download this version of
Form CM-912
for the current year.
Form CM-912 Survivor's Form for Benefits Under the Black Lung Benefits Act
What Is Form CM-912?
This is a legal form that was released by the U.S. Department of Labor - Division of Coal Mine Workers' Compensation on November 1, 2019 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form CM-912?
A: Form CM-912 is the Survivor's Form for Benefits Under the Black Lung Benefits Act.
Q: Who is eligible to use Form CM-912?
A: Survivors of coal miners who have passed away due to black lung disease are eligible to use Form CM-912.
Q: What is the purpose of Form CM-912?
A: The purpose of Form CM-912 is to apply for benefits under the Black Lung Benefits Act as a survivor of a coal miner.
Q: Is there a fee to submit Form CM-912?
A: No, there is no fee to submit Form CM-912.
Form Details:
- Released on November 1, 2019;
- The latest available edition released by the U.S. Department of Labor - Division of Coal Mine Workers' Compensation;
- Easy to use and ready to print;
- Yours to fill out and keep for your records;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form CM-912 by clicking the link below or browse more documents and templates provided by the U.S. Department of Labor - Division of Coal Mine Workers' Compensation.
Download Form CM-912 Survivor's Form for Benefits Under the Black Lung Benefits Act
1
2
