Form Ee-2 - Survivor'S Claim For Benefits Under The Energy Employees Occupational Illness Compensation Program Act - United States Department Of Labor, Office Of Workers' Compensation Programs Page 3
Download a blank fillable Form Ee-2 - Survivor'S Claim For Benefits Under The Energy Employees Occupational Illness Compensation Program Act - United States Department Of Labor, Office Of Workers' Compensation Programs in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ee-2 - Survivor'S Claim For Benefits Under The Energy Employees Occupational Illness Compensation Program Act - United States Department Of Labor, Office Of Workers' Compensation Programs with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3Instructions 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, 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 DEEOIC Central Mail Room Correspondence
P.O. Box 8306
London, KY 40742-8306
Deceased Em ployee I nform ation
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).
Aw ards and Other I nform ation
Question 16 – Mark the appropriate box indicating whether you or the deceased employee 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 filed any state workers’ compensation claims related
to 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 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 Justice
(DOJ) 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 21 – Mark the appropriate box indicating whether you or the deceased employee filed for an award from DOJ under Section 4 of RECA.
Other Potential Survivors
Item 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 EEOICPA,
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
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
et seq
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 to consider other relevant matters. (4) Information 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) Information may be given to Federal, state, and local agencies for law
enforcement purposes, to obtain information relevant to a decision under EEOICPA, 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 (TIN) is mandatory. We are authorized to
collect your SSN or TIN under Executive Order 9397 (November 22, 1943). Your SSN or TIN, 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 the 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 EEOICPA 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
December 2013
Page 3
Previous Page
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Ee-1 - Worker's Claim For Benefits Under The Energy Employees Occupational Illness Compensation Program Act - U.s. Department Of Labor, Office Of Workers' Compensation Programs
Legal
Claim For Benefits Under The Law Enforcement Officers', Firemen's, Rescue Squad Workers' And Civil Air Patrol Members' Death Benefits Act
Financial
Instructions For Form Ct-603 - Claim For Ez Investment Tax Credit And Ez Employment Incentive Credit - New York State Department Of Taxation And Finance - 2004
Financial
Instructions For Form It-254 - Claim For Residential Fuel Oil Storage Tank Credit Personal Income Tax - New York State Department Of Taxation And Finance - 2003
Financial
Instructions For Form Ct-603 - Claim For Ez Investment Tax Credit And Ez Employment Incentive Credit - New York State Department Of Taxation And Finance - 2002
Financial
Form Ca-2 - Notice Of Occupational Disease And Claim For Compensation - United States Department Of Labor, Office Of Workers Compensation Programs
Legal
Form A-2 - Employer's Application For The Privilege Of Paying Compensation Provided In The Mississippi Workers' Compensation Act As Self-insurer Form - Mississippi Workers' Compensation Comission
Legal
Related Categories
Parent category: Legal