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

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U.S. Department of Labor
Survivor’s Claim for Benefits Under the Energy
Employees Occupational Illness Compensation Program
Office of Workers’ Compensation Programs
Division of Energy Employees Occupational
Act
Illness Compensation
Note: Please read the instructions on page 3 before completing this form. Provide all information
OMB Control No:
1240-0002
Expiration Date:
12/31/2016
requested below, and sign and date the bottom of Page 2. Do not write in the shaded areas.
Deceased Employee Information (
please print clearly)
1. Name
2. Sex
3. Social Security Number
(Last, First, Middle Initial)
Male
Female
4. Date of Birth
5. Date of Death
6. Was an autopsy performed on the employee?
YES - List Medical Facility:
Month
Day
Year
Month
Day
Year
NO
DON’T KNOW
Survivor Information (
please print clearly)
7. Name
8. Sex
9. Social Security Number
(Last, First, Middle Initial)
Male
Female
10. Date of Birth
11. Your relationship to the deceased employee
spouse
child
step-child
adopted child
Month
Day
Year
parent
grandparent
grandchild
Other:
12. Address
13. Telephone Numbers
(Street, Apt. #, P.O. Box)
(
)
-
a. Home:
(City, State, ZIP Code)
(
)
-
b. Other:
14. Identify the Diagnosed Condition(s) Being Claimed as Work-Related
(check box and list specific diagnosis)
15. Date of Diagnosis
Cancer
(List Specific Diagnosis Below)
Month
Day
Year
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
YES
NO
toxic substance?
17. Have you or the deceased employee filed any state workers’ compensation claims in connection with any condition(s)
YES
NO
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
YES
NO
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
YES
NO
or state workers’ compensation?
20. Have you or the employee applied for an award under Section 5 of the Radiation Exposure Compensation Act (RECA)?
YES
NO
If yes, provide RECA Claim #:
21. Have you or the employee applied for an award under Section 4 of RECA?
YES
NO
Form EE-2
Page 1
December 2013
Next Page

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