EE-16 and EN-16 Letter to Claimant

U.S. DEPARTMENT OF LABOR

Office of Workers’ Compensation Programs Division of Energy
Employees Occupational Illness Compensation
DOL DEEOIC Central Mail Room
P.O. Box 8306
London, KY 40742-8306

Employee Name
Case ID Number:
Dear
The information requested in the attached enclosure is required in connection with your claim for
benefits under the Energy Employees Occupational Illness Compensation Program Act of 2000
(EEOICPA). This information will be used to decide if you are entitled to benefits, and if so, the level
of those benefits. The Division of Energy Employees Occupational Illness Compensation (DEEOIC)
will not be able to process your claim for benefits without this information. You must completely
answer all questions and return the enclosure within 30 days of the date of this letter to the following
address:
U.S. Department of Labor
OWCP/DEEOIC
P.O. Box 8306
London, KY 40742-8306
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Pub. L. 100-503 provides that the statements on the enclosure and other information in your claim file
may be verified through computer matches. DEEOIC may also ask that you submit any factual evidence
it deems necessary to support your statements.
READ ALL INSTRUCTIONS CAREFULLY BEFORE FILLING OUT THE ENCLOSED EN-16.
YOU MUST ANSWER ALL OF THE QUESTIONS. IF THE QUESTION DOES NOT APPLY
TO YOUR CLAIM, STATE “NOT APPLICABLE (N/A)” OR “NONE.”
If you need more space to fully answer any of the questions, use another sheet of paper with your name
and ClaP,'1XPEHUDWWKH WRS6LJQDQGGDWHHDFK H[WUDVKHHW

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OMB Control No. 1240-0002
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WARNING: A FALSE OR EVASIVE ANSWER TO ANY QUESTION, OR THE OMISSION
OF AN ANSWER, MAY BE GROUNDS FOR FORFEITING YOUR BENEFITS AND SUBJECT
YOU TO CIVIL LIABILITY. A FRAUDULENT ANSWER MAY RESULT IN CRIMINAL
PROSECUTION. ALL STATEMENTS ARE SUBJECT TO INVESTIGATION FOR
VERIFICATION.
Your signature certifies that you have supplied all information requested by the enclosure. If you have
any questions about completing the enclosure, call me at
or write to me at the address
given above.
Sincerely,

Enc: Form EN-16

OMB Control No. 1240-0002
Expiration Date: ;;;;;;

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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 20 minutes per response, including time
for reviewing instructions, searching existing data sources, gathering the data needed, and completing
and reviewing the collection of information. The obligation to respond to this collection is required to
obtain EEOICPA benefits (20 CFR 30.505). Send comments regarding the burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, send them 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/EN16. Do not submit the completed form to this address.

OMB Control No. 1240-0002
Expiration Date: ;;;;

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Case ID Number:
Claimant Name:

PART A – TORT SUITS FILED AGAINST BERYLLIUM VENDORS OR ATOMIC WEAPONS
EMPLOYERS

Have you filed a tort suit (other than an administrative or judicial proceeding for workers’
compensation) against a beryllium vendor or atomic weapons employer related to an exposure for which
you would be eligible to receive compensation under EEOICPA? Yes or No: __________


If Yes, state:BBBBBBBBBBBBB

Date of filing:______________________________________________________
Party or parties involved:___________________________________________
Date tort suit was dismissed:________________________________________
List any other tort suits on an extra sheet.
PART B – THIRD PARTY SETTLEMENTS OR AWARDS

Have you received any settlement or award from a claim or suit (other than a claim for workers’
compensation) against a third party (other than a beryllium vendor or atomic weapons employer listed in
Part A above) related to an exposure for which you would be eligible to receive compensation under
EEOICPA? Yes or No: __________


If Yes, state:BBBBBBBBBBBBB

Date of judgment or settlement:______________________________________
Party or parties involved:___________________________________________
Type of suit or settlement:__________________________________________
Amount of award or settlement:_______________________________________
List any other third party settlements or awards on an extra sheet.

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OMB Control No. 1240-0002
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PART C – STATE WORKERS’ COMPENSATION
1.
Have you filed for or received any state workers’ compensation benefits on account of your
claimed illness(es)? Yes or No: ________
2.

If you answered “Yes,” please tell us the following information:

Date of filing:______________________________________________________
State in which you filed:______________________________________________
Illness(es) for which you received benefits:_______________________________
Name of employer, insurer or state that paid:_____________________________
Amount of monetary benefits received: $________________________________
Type of benefits (disability, impairment, etc.):____________________________
PART D – FRAUD CHARGES

Have you either pled guilty to or been convicted on any charges of having committed fraud in
connection with an application for or receipt of benefits under EEOICPA or any other federal or state
workers’ compensation law? Yes or No: ___________


If Yes, state:BBBBBBBBBB

Date of conviction or guilty plea:___________________________________
Jurisdiction where fraud charges were brought:________________________
PART E – SURVIVORS OF DECEASED EMPLOYEES

Are you claiming compensation under EEOICPA as a survivor of a deceased employee? Yes or
No:____________


If Yes, state:BBBBBBBBBB

Your relationship to the deceased employee:__________________________
If spouse, list date and place of marriage:_____________________________
If other than spouse, list your date of birth:___________________________
Do you know of any other persons who may also be eligible to receive compensation under
3.
EEOICPA as a survivor of the deceased employee upon whom your claim is based? Yes or
No:___________

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4.

If Yes, state:

Name of other survivor:_______________________________________________________________
Relationship of other survivor to deceased employee:________________________________________
Address and/or telephone number of other survivor (if known):________________________________
List any other survivors on an extra sheet.
PART F – CORRECTIONS
If the name, address or Case ID Number shown at the top of the first page of the accompanying letter is
incorrect, provide the correct information in the space provided below. (Do not complete if the
information is correct).
Name:BBBBBBBBBBBBBBBBBBBBBBB Case ID Number:________________________
Address:______________________ 7HOHSKRQH1XPEHUBBBBBBBBBBBBBBBBBBBBBB
PART G – CERTIFICATION
I know that anyone who fraudulently conceals or fails to report information that would have an effect on
benefits, or who makes a false statement or misrepresentation of a material fact in claiming a payment or
benefit under EEOICPA may be subject to criminal prosecution, from which a fine and/or imprisonment
may result.
I understand that I must immediately report to DEEOIC any tort suit or state workers’ compensation
settlement I receive, any tort suit I file against a beryllium vendor or atomic weapons employer, any
change in the status of a survivor, and any conviction for fraud committed against this program or any
other federal or state workers’ compensation law.
I certify that all the statements made in response to questions on this enclosure are true, complete and
correct to the best of my knowledge and belief. I have placed “Not Applicable (N/A)” or “None” next to
those questions that do not apply to me or my claim.

_________________________
Signature

OMB Control No.
1240-0002 Expiration Date:
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________________
Date

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