Notice to Reviewer

Note to Reviewers:
We have made four changes to the CM-921, adding one item that changes the
numbering of subsequent fields. The first change is to require the
insurance carrier that completes the CM-921 to enter the mine operator’s
Federal Employer Identification Number (EIN) of the front side of the card.
This will be item number 2.
We are adding the EIN because it is already known to the insurance carrier
as it is shown on the policy itself or on the employer’s application for
coverage to the insurance carrier, and because it will significantly enhance
the proper identification of the named insured. Many thousands of coal
operators have been insured and identified since Black Lung Benefits Act
required insurance coverage, and many small coal company names are similar.
By matching policies to the named insured and using the EIN to verify that
the proper company has been covered, the Department of Labor will be able to
reduce the chance of misidentification.
Item number 3 will be:
Code)”

“Address (include street, City, County, State, Zip

Item number 4 (formerly Item #3) will be “Policy Number.” Item number 5
(formerly Item 4) will be “Policy Dates.” Item number 6 (formerly Item 5)
will be “Coverage is provided for operations in the following states.”
Numbers 7-9 (formerly Items 6-8) will be the insurance carrier, its address,
and its phone number. Number 10 (formerly Item 9) will be “Authorized
Signature for Carrier.”
The second change is to the top item on the reverse side of the card:
Change: Indicate below the name and location of the insured mine(s)
to:
Indicate below the name and location of the insured mine(s) and
subsidiary(ies).
Many coal mine operators have subsidiary companies and mine sites, often
operating under different names. A coal miner or survivor, filing a claim
long after the miner’s last employment with a company, may remember the mine
name but not the company’s name. Because these subsidiaries are already
included in the policy issued by the insurance carrier, obtaining and
reporting this information would require little additional burden on the
carriers. The CM-921 has always required the listing of mine sites; this
change expands that requirement to include subsidiaries.
The third change is to alter NAME OF MINE to:
NAME AND LOCATION OF MINE

The fourth change is to alter NAME LOCATION to:
NAME AND LOCATION OF SUBSIDIARY
---------------------------------------------------------------The revisions to the CM-921 will appear as follows:
Notice of Issuance of Insurance Policy_____________________
1. Mine Operator
2. Mine Operator’s Federal Employer Identification Number (FEIN)
3. Address (include Street, City, County, State, Zip Code)

(reverse side of CM-921)

Indicate below the name and location of the insured mine(s) and subsidiary(ies).

NAME AND LOCATION OF MINE

NAME AND LOCATION OF SUBSIDIARY

_________________________

_______________________________

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_______________________________

_________________________

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