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Claim For Benefits Under Energy Employees Occupational Illness Compensation Program Act EE-1 - Official Federal Forms
| Claim For Benefits Under Energy Employees Occupational Illness Compensation Program Act Form. This is a national form and can be used in US Dept Of Labor . |
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Office of Workers' Compensation Programs Division of Energy Employees Occupational Illness Compensation OMB Control No: 1240-0002 Note: Please read the instructions on page 2 before filling out this form. Provide all Expiration Date: 10/31/2013 information requested, and sign and date the bottom of page 1. Do not write in the Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act U.S. Department of Labor shaded areas. Employee Information (Please Print Clearly) 1. Name (Last, First, Middle Initial) 3. Date of Birth Month Day Year 2. Social Security Number 4. Sex Male Female 5. Dependents Spouse Children Other: 6. Address (Street, Apt. #, P.O. Box) 7. Telephone Number(s) a. Home: ( ( ) ) 9. Date of Diagnosis Month Day Year (City, State, ZIP Code) b. Other: 8. Identify the Diagnosed Condition(s) Being Claimed as Work-Related (check box and list specific diagnosis) Cancer (List Specific Diagnosis Below) a. b. c. Beryllium Sensitivity Chronic Beryllium Disease (CBD) Chronic Silicosis Other Work-Related Condition(s) due to exposure to toxic substances or radiation (List Specific Diagnosis Below) a. b. c. Awards and Other Information 10. Have you filed a lawsuit based on exposure to radiation, beryllium, asbestos or any other toxic substance? 11. Have you filed any state workers' compensation claims in connection with any condition(s) you claim in Item 8? 12. Have you or another person received a settlement or other award in connection with a lawsuit or state workers' compensation claim described in Questions 10 or 11? 13. Have you either pled guilty to or been convicted of any charges connected with an application for or receipt of federal or state workers' compensation? 14. Have you applied for an award under Section 5 of the Radiation Exposure Compensation Act (RECA)? If yes, provide RECA Claim #: 15. Have you applied for an award under Section 4 of RECA? YES NO YES YES YES YES YES NO NO NO NO NO Employee Declaration Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain compensation as provided under EEOICPA or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. Any change to the information provided on this form once it is submitted must be reported immediately to the district office responsible for the administration of the claim. I hereby make a claim for benefits under EEOICPA and affirm that the information I have provided on this form is true. If applicable, I authorize the Department of Justice to release any requested information, including information related to my RECA claim, to the U.S. Department of Labor, Office of Workers' Compensation Programs (OWCP). Furthermore, I authorize any physician or hospital (or any other person, institution, corporation, or government agency, including the Social Security Administration) to furnish any desired information to the U.S. Department of Labor, Office of Workers' Compensation Programs. Resource Center Date Stamp Employee Signature Date Page 1 Form EE-1 November 2009 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Form EE-1 Complete all items on the form. If additional space is required to explain or clarify any point, attach a supplemental statement to the form. If the requested information is not submitted, the responsible party should explain the reason(s) for the delay and indicate when the information will be forthcoming. Submit the completed claim form and all other pertinent documentation to the appropriate district office administering EEOICPA in the region where your most recent covered employer is/was located. Item 8 Identify the specific physician-diagnosed condition(s) that you claim are work related. Do not list the symptoms (e.g. aches, pains, cough, wheezing, breathing problems, etc.) associated with the diagnosed condition(s). If you require additional space, attach a signed supplemental statement to this form. Item 9 List the date a physician first diagnosed the claimed condition(s) you listed in Item 8. Question 10 Mark the appropriate box indicating whether you have filed a civil lawsuit based on exposure to any toxic substance. If you mark the box for YES, provide copies of all pertinent court documentation. Question 11- Mark the appropriate box indicating whether you have filed any state workers' compensation claims in connection with any condition(s) you claim in Item 8. If you mark the box for YES, provide copies of all pertinent state workers' compensation documentation. Question 12 Mark the appropriate box indicating whether you or another person received a settlement or other type of award from a lawsuit or a state workers' compensation claim described in Questions 10 or 11. If you mark the box for YES, provide copies of all pertinent documentation. Question 13 - Mark the appropriate box indicating whether or not you have ever pled guilty to or been convicted on any charges connected to an application for or receipt of federal or state workers' compensation. Question 14 Mark the appropriate box indicating whether you have filed for an award from the Department of Justice under Section 5 of the Radiation Exposure Compensation Act (RECA). If you mark the box for YES, provide the claim number associated with that RECA claim in the space provided. Question 15 Mark the appropriate box indicating whether you have filed for an award from the Department of Justice under Section 4 of RECA. Privacy Act Statement In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Energy Employees Occupational Illness Compensation Program Act (42 USC 7384 .) (EEOICPA) is administered by the Office of Workers' Compensation Programs of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information received will be used to determine eligibility for, and the amount of, benefits payable under EEOICPA, and may be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agencies or private entities that employed the employee to verify statements made, answer questions concerning the status of the claim and
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