EE-1 English Worker's Claim for Benefits Under the Energy Employees O

U.S. Department of Labor

Worker’s Claim for Benefits Under the Energy
Employees Occupational Illness Compensation
Program Act

Office of Workers’ Compensation Programs
Division of Energy Employees Occupational
Illness Compensation
OMB Control No:
1240-0002
Note: 5ead the instructions on page 2 before filling out this form. Provide all
Expiration Date:
XX/XX/20XX
information requested, and sign and date the bottom of page 1. Do not write in the

shaded areas.

Employee Information (Print Clearly)
1. Name (Last, First, Middle Initial)

2. Social Security Number

3. Date of Birth

4. Sex
Month

6. Address

Day

5. Dependents

Male

Year

Female

Spouse

Children

Other:

7. Telephone Number(s)

(Street, Apt. #, P.O. Box)

a. Home:

(

)

-

b. Other:

(

)

-

(City, State, ZIP Code)

8. Identify the Diagnosed Condition(s) Being Claimed as Work-Related (check box and list specific diagnosis)
9. Date of Diagnosis
Month
Day
Year

Cancer (List Specific Diagnosis Below)
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?
12. Have you or another person received a settlement or other award in connection with a lawsuit or state workers’
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
federal or state workers’ compensation?
14. Have you applied for an award under Section 5 of the Radiation Exposure Compensation Act (RECA)?

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

If yes, provide RECA Claim #:
15. Have you applied for an award under Section 4 of RECA?

Employee 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.

Employee Signature

Resource Center Date Stamp

Date

Page 1

Form EE-1
July 2024

Instructions for Completing Form EE-1
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:
U.S. Department of Labor
OWCP/DEEOIC
P.O. Box 8306
London, KY 40742-8306
Alternatively,
y, yyou can complete,
p
, digitally
g
y sign,
g , and submit yyour Form EE-1 online via the Energy
gy Document Portal ((EDP) at
https://eclaimant.dol.gov. If you choose to complete your form online via the EDP, mailing the form is not necessary.

I llness(es)) Being
g Claimed
d
Item 8 – Identify the specific 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). If you require additional space, attach a signed supplemental
statement to this form.
Item 9 – List the date a physician first diagnosed the claimed condition(s) you listed in Item 8.

Awardss and
d Otherr Information
n
Question 10 – Mark the appropriate box indicating whether you 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 11- Mark the appropriate box indicating whether you have filed any state workers’ compensation claims in connection with any condition(s)
you claim in Item 8. If you mark the box for YES, provide copies of all pertinent state workers’ compensation documentation.
Question 12– Mark the appropriate box indicating whether you or another person received a settlement or other type of award from a lawsuit or a
state workers’ compensation claim described in Questions 10 or 11. If you mark the box for YES, provide copies of all pertinent documentation.
Question 13 - 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 14 – Mark the appropriate box indicating whether you have filed for an award from the Department of Justice 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 15 – Mark the appropriate box indicating whether you have filed for an award from the Department of Justice under Section 4 of RECA.

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 Illness

Compensation Program Act (42 USC 7384 et seq .) (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 17 minutes 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 30.100(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 OMB Control No. 1240-0002 and Form
EE-1. Do not submit the completed form to this address.

Page 2

Form EE-1
July 2024