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

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U.S. Department of Labor
Worker’s Claim for Benefits Under the Energy
Employees Occupational Illness Compensation
Office of Workers’ Compensation Programs
Division of Energy Employees Occupational
Program Act
Illness Compensation
Note:
Please read the instructions on page 2 before filling out this form. Provide all
OMB Control No:
1240-0002
Expiration Date:
12/31/2016
information requested, and sign and date the bottom of page 1. Do not write in the
shaded areas.
Employee Information (
Please Print Clearly)
1. Name
2. Social Security Number
(Last, First, Middle Initial)
3. Date of Birth
4. Sex
5. Dependents
Male
Female
Spouse
Children
Other:
Month
Day
Year
6. Address
7. Telephone Number(s)
(Street, Apt. #, P.O. Box)
(
)
-
a. Home:
(City, State, ZIP Code)
(
)
-
b. Other:
8. Identify the Diagnosed Condition(s) Being Claimed as Work-Related
(check box and list specific diagnosis)
9. Date of Diagnosis
Cancer
(List Specific Diagnosis Below)
Month
Day
Year
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?
YES
NO
11. Have you filed any state workers’ compensation claims in connection with any condition(s) you claim in Item 8?
YES
NO
12. Have you or another person received a settlement or other award in connection with a lawsuit or state workers’
YES
NO
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
YES
NO
federal or state workers’ compensation?
14. Have you applied for an award under Section 5 of the Radiation Exposure Compensation Act (RECA)?
YES
NO
If yes, provide RECA Claim #:
15. Have you applied for an award under Section 4 of RECA?
YES
NO
Employee Declaration
Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to
Resource Center Date Stamp
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. 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.
Employee Signature
Date
Form EE-1
Page 1
December 2013
Next Page

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