Official Federal Forms > US Dept Of Labor
Claim For Survivor Benefits Under Energy Employees Occupational Illness Compensation Program Act EE-2 - Official Federal Forms
| Claim For Survivor 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 Note: Please read the instructions on page 3 before completing this form. Provide all information OMB Control No: 1240-0002 Expiration Date: 10/31/2013 requested below, and sign and date the bottom of Page 2. Do not write in the shaded areas. Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act U.S. Department of Labor Deceased Employee Information (please print clearly) 1. Name (Last, First, Middle Initial) 2. Sex Male Female 3. Social Security Number 4. Date of Birth Month Day Year 5. Date of Death Month Day Year 6. Was an autopsy performed on the employee? YES - List Medical Facility: NO DON'T KNOW Survivor Information (please print clearly) 7. Name (Last, First, Middle Initial) 10. Date of Birth Month Day Year 8. Sex Male Female 9. Social Security Number 11. Your relationship to the deceased employee spouse parent child grandparent step-child adopted child grandchild Other: 13. Telephone Numbers a. Home: 12. Address (Street, Apt. #, P.O. Box) ( ( ) ) 15. Date of Diagnosis Month Day Year (City, State, ZIP Code) b. Other: 14. Identify the Diagnosed Condition(s) Being Claimed as Work-Related (check box and list specific diagnosis) Cancer (List Specific Diagnosis Below) a. b. c. d. 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. d. Awards and Other Information 16. Have you or the deceased employee filed a lawsuit based on exposure to radiation, beryllium, asbestos or any other toxic substance? 17. Have you or the deceased employee filed any state workers' compensation claims in connection with any condition(s) you claim in Item 14? 18. Have you, the deceased employee, or another person received a settlement or other award in connection with a lawsuit or state workers' compensation claim described in questions 16 or 17? 19. Have you either pled guilty to or been convicted on any charges connected with an application for or receipt of federal or state workers' compensation? 20. Have you or the employee applied for an award under Section 5 of the Radiation Exposure Compensation Act (RECA)? If yes, provide RECA Claim #: 21. Have you or the employee applied for an award under Section 4 of RECA? Page 1 YES NO YES YES YES YES YES NO NO NO NO NO Form EE-2 November 2009 American LegalNet, Inc. www.FormsWorkFlow.com Other Potential Survivors 22. List any person(s) who may also qualify as a survivor of the deceased employee and include the following information: Relationship to the deceased employee Name a. Address Home: Other: Home: Other: Home: Other: Home: Phone Number(s) b. c. d. Other: Home: e. Other: Home: f. Other: Home: g. Other: Home: Other: Home: Other: Home: h. i. j. Other: Survivor 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 Claimant Signature Page 2 Date Form EE-2 November 2009 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Form EE-2 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 the employee's most recent covered employer is/was located. Item 14 - Identify the employee's 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). Attach to the claim form any pertinent medical documentation and copy of the employee's death certificate. If you require additional space, attach a signed supplemental statement to this form. Item 15 - List the date a physician first diagnosed the claimed condition(s). Question 16 Mark the appropriate box indicating whether you or the deceased employee 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 17 Mark the appropriate box indicating whether you or the deceased employee have filed any state workers' compensation claims in connection with any condition(s) you claim in Item 14. If you mark the box for YES, provide copies of all state workers' compensation documentation. Question 18 Mark the appropriate box indicating whether you, the deceased employee or another person received a settlement or other type of award for a lawsuit or a state workers' compensation claim described in Questions 16 or 17. If you mark the box for YES, provide copies of all pertinent documentation. Question 19 - 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 20 Mark the appropriate box indicating whether you or the deceased employee filed for an award from the Department of
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