Form Ee 2 – Fill Out and Use This PDF

I nstructions for Completing Form EE- 2

Complete all items on the form. I f additional space is required to explain or clarify any point, attach a supplemental statement to the form. I f the requested information is not submitted, you 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 following address:

DOL DEEOI C Central Mail Room Correspondence

P.O. Box 8306

London, KY 40742-8306

Deceased Em p lo y ee I n f or m at io n

I t em 14 - I dentify 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. I f you require additional space, attach a signed supplemental statement to this form. I tem 15 - List the date a physician first diagnosed the claimed condition(s).

Aw ar d s an d Ot h er I n f o r m at io n

Question 16 – Mark the appropriate box indicating whether you or the deceased employee filed a civil lawsuit based on exposure to any toxic substance. I f 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 filed any state workers’ compensation claims related to any condition(s) you claim in I tem 14. I f 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 award for a lawsuit or a state workers’ compensation claim described in Questions 16 or 17. I f 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 Justice (DOJ) under Section 5 of the Radiation Exposure Compensation Act (RECA). I f you mark the box for YES, provide the claim number associated with that RECA claim in the space provided.

Question 21 – Mark the appropriate box indicating whether you or the deceased employee filed for an award from DOJ under Section 4 of RECA.

Ot h er Po t en t ial Su r v iv o r s

I tem 22 - Every eligible survivor of a covered employee must be identified prior to the payment of any compensation. List any individual who may also qualify as a survivor of the deceased employee and provide the additional information requested in this item, if known. Under EEOI CPA, certain limitations apply to the definition of persons who may qualify as an eligible survivor. Eligible survivors of a deceased employee may include his or her: surviving spouse, child (biological, step or adopted), parent, grandchild, or grandparent . Any claim for survivor benefits must be accompanied by proof of relationship to the deceased employee. This includes, but may not be limited to, a copy of a marriage certificate, birth certificate, or adoption papers.

Privacy Act Statement

I n accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Energy Employees Occupational

I llness Compensation Program Act (42 USC 7384 et seq.) (EEOI CPA) 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) I nformation received will be used to determine eligibility for, and the amount of, benefits payable under EEOI CPA, and may be verified through computer matches or other appropriate means. (3) I nformation 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 to consider other relevant matters. (4) I nformation may be disclosed to physicians and other health care providers for use in providing treatment, performing evaluations for the Office of Workers’ Compensation Programs, and for other purposes related to the medical management of the claim. (5) I nformation may be given to Federal, state, and local agencies for law enforcement purposes, to obtain information relevant to a decision under EEOI CPA, to determine whether benefits are being paid properly, including whether prohibited payments have been made, and, where appropriate, to pursue debt collection actions required or permitted by the Debt Collection Act . (6) Disclosure of your social security number (SSN) or tax identification number (TI N) is mandatory. We are authorized to collect your SSN or TI N under Executive Order 9397 (November 22, 1943). Your SSN or TI N, and other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal government, and for other purposes required or authorized by law. (7) Failure to disclose all requested information may delay t he processing of the claim or the payment of benefits, or may result in an unfavorable decision.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to the information collections on this form unless it displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 21minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. You are required to respond to this collection to obtain EEOI CPA benefits (20 CFR 30.101(a)). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers’ Compensation Programs, Room S3524, 200 Constitution Avenue N.W., Washington, D.C. 20210, and reference both OMB Control No. 1240-0002 and Form EE-2. Do not submit the completed form to this address.

	Form EE-2
Page 3	November 2015