EE-10 Letter to Claimant

U.S. Department of Labor

Impairment/Wage-Loss Benefits Claim Under
the Energy Employees Occupational Illness
Compensation Program Act

Office of Workers’ Compensation
Programs Division of Energy Employees
Occupational Illness Compensation

Note: Read the instructions on page 2 before filling out this form. Provide all
information requested, and sign and date the bottom of page 1. Do not write in
the shaded area.

OMB Control No. 1240-0002
Expiration Date: XX/XX20XX

Employee Information (Please Print Clearly)
1. Name (Last, First, Middle Initial)
3. Address (Street, Apt. #, P.O. Box)

(City, State, ZIP Code)

2. Case ID Number
4. Telephone Number(s)
a. Home:

(

b. Other:

(

)
)
-

5. Options and Selection for Impairment or Wage-Loss Claim(s)
Option A - I have not received a prior impairment and/or wage-loss award because of my accepted condition(s). This claim is for an
initial award for whole-person impairment and/or wage-loss benefits. Select one or both, as applicable:
□ Initial claim for whole-person impairment

□ Initial cClaim for wage-loss benefit
Date of iInitial wage-loss from accepted illness
/
Period of wage-loss claimed
/
(Month/Year TO:

/

(Month/Year)
(Month/Year)

Option B – I have previously received an award for impairment and/or wage-loss because of my accepted condition(s). This claim is
for increased whole-person impairment and/or additional wage-loss. For increased impairment, it has been at least 2 years since my
last award. For additional wage-loss, it has been one year since my last award. Select one or both, as applicable.
□ Claim for increased whole-person impairment

□ Claim for additional wage-loss benefit

6. For Impairment Claims – identify the physician you would like to perform your impairment evaluation: (Select only one)
□ DEEOIC will arrange for a qualified physician, known as a Contract Medical Consultant (CMC), to perform the impairment
evaluation.
□ A physician of my choosing will perform my whole person impairment.
Physician Name:
Address:
Phone Number:

Claimant 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

Date

Instructions for Completing Form EE-10
Impairment: “Whole-person impairment” (or “impairment”) is a percentage rating that represents the extent of impairment of a person based on the
organ(s) and or system(s) affected by the accepted illness(es). The percentage of impairment reflects how severely your accepted illness(es) affect your
body as a whole. The available monetary benefit is $2,500 for every percentage point, up to a maximum monetary award of $250,000 under Part E. An
impairment rating must be performed by an appropriate physician once your accepted illness has reached maximum medical improvement, meaning that it
is unlikely to improve with additional treatment. In order for a physician to be considered able to perform impairment evaluations under EEOICPA, the
physician must hold a valid medical license and Board certification (or eligibility) in an appropriate field of expertise. The physician must also be certified
by the American Board of Independent Medical Examiners or the International Academy of Independent Medical Evaluators or possess the requisite
professional experience and medical work background in interpreting the American Medical Association’s Guides to the Evaluation of Permanent
Impairment (AMA’s Guides) to provide such ratings.
An employee previously awarded impairment benefits may file a claim for increased impairment benefits for the same covered illness included in the
previous award. The employee may not submit a claim form for an increased impairment rating earlier than two years from the date of the last
final decision on impairment. A waiver of the two-year waiting period may be granted if:

(1) A new covered illness has been accepted since a previous final decision awarding impairment and the condition relates
to an organ system that was not included in a prior rating.

(2) The claimant requests a waiver of the two-year rule and submits medical evidence, documenting since the last

impairment rating, that the accepted condition(s) has caused a substantial detrimental effect to the claimant’s living
circumstances, one or more ADLs, or medical status.

Wage-Loss: (1) are awarded if the accepted illness(es) caused or contributed to an employee’s loss of earnings; and (2) are payable only for the
calendar years of wage-loss experienced before an employee’s normal Social Security retirement age. A person’s normal retirement age is based on
the year when he/she was born and is usually 65 years of age but can be as high as 67 years of age (see the enclosed Social Security Retirement
Age Table). Wage-loss benefits are payable only through the calendar year when normal retirement age is reached. In addition, earnings and
medical documentation must be submitted to support the period of wage-loss being claimed.
Complete all the applicable items on the form. This form may be completed by a covered employee, a qualifying survivor of a covered employee, or
someone with the legal capacity to sign on behalf of another person (i.e., attorney-in-fact). The claimant making the claim must complete all
applicable items and sign 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, you can complete this form online via the Energy 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.
Item 2 – List Case ID Number associated with the claim for an illness previously accepted under Part E of EEOICPA.
Item 5 – Mark the appropriate box to specify whether you are claiming initial impairment or wage-loss, or increased impairment or
additional wage-loss benefits. For wage-loss enter the month and year the initial wage-loss began and the period you are claiming wage-loss
(i.e., January/2001 to December/2006). An initial claim means the first time you are filing for benefits, either impairment, wage-loss, or
both. An increased claim means you have previously been awarded impairment or wage-loss benefits, the required
elapsed time has passed (2 years for impairment, 1 year for wage-loss), and you are now filing a subsequent claim to determine whether you have
an increase in impairment or whether you have another year of wage-loss.
Item 6 – Only one option may be selected. Mark the appropriate box to specify whether you would like DEEOIC to submit your claim to a CMC
for a medical records evaluation. If you select this option you will need to submit an Activities of Daily Living Form, along with the previous 12
months of medical records pertaining to the claimed illness(es). If you select a physician of your choice you must provide their name, address, and
telephone number. Your physician of choice must be qualified to conduct an impairment evaluation as stated above.

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Form EE-10
July 2024

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) 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 10 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 § 30.505(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. Do not submit the completed form to this address.
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Form EE-10
July 2024