Official Federal Forms > US Dept Of Labor
Notice Of Termination Suspension Reduction Or Increase In Benefit Payments CM-908 - Official Federal Forms
| Notice Of Termination Suspension Reduction Or Increase In Benefit Payments Form. This is a national form and can be used in US Dept Of Labor . |
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Notice of Termination, Suspension, Reduction, or Increase In Benefit Payments U.S. Department of Labor Office of Workers' Compensation Programs Division of Coal Mine Workers' Compensation Privacy Act Statement: In accordance with the Privacy Act of 1974, as amended, (5 U.S.C. a), you are hereby notified that: This report is required by the Black Lung Benefits Act (30 U.S.C. 90 1 et. seq.) and is mandatory. It is to be completed in full and filed with the Office of Workers' Compensation Programs within 16 days following the termination of benefits, and immediately following the suspension, reduction or increase of benefits are paid under Title IV of the Federal Mine Safety & Health act of 1977, as amended to insure that correct benefits are paid. Failure to report can result in a civil penalty of not more than $500 for each such failure or refusal. Name and Address of Payee (Please Print) Include ZIP Code Name Address Line 1 Address Line 2 City 1. Name of disabled or deceased miner State ZIP Distribution: Copy 3 - Payee's Copy Copy 2 - Operator's Copy Copy 1 - Send To: OMB No. 1240-0030 Expires: 08-31-2015 U.S. Department of Labor Office of Workers' Compensation Programs Division of Coal Mine Workers' Compensation 2. DOL Claim Number 3. Name of coal miner operator 4. Name of insurance carrier 5. Action taken: 6. Reasons why action taken: Terminated Suspended Reduced Increased a. Date of Last Payment (mm/dd/yy) 7. Summary of Payments a. Name of Payee b. Amount of Last Payment c. Amount of Reduced/ Increased Payment d. Date Benefits Will Resume (mm/dd/yy) e. Date of This Notice (mm/dd/yy) b. From c. To d. Date Benefits Will Resume e. Amount Paid Per Month f. Total 8. Signature of person issuing this notice 9. Title 10. Telephone number Public Burden Statement Public reporting burden for this collection of information is estimated to average 12 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Workers' Compensation Programs, U.S. Department of Labor, Room C-3520, 200 Constitution Avenue, NW., Washington, DC. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE. Notice If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from DCMWC in the form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will provide you with copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact our office or your claims examiner to ask about this assistance. Note: According to the Paperwork Reduction Act of 1995, persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. U.S. GPO:2001-479-595/89873 1 - District Director's Copy Form CM-908 (Rev. 06-97) American LegalNet, Inc. www.FormsWorkFlow.com
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