U.S. DEPARTMENT OF LABOR Energy Employees Occupational Illness Compensation Program Act (EEOICPA) 1001 Lakeside Ave., Suite 350 Cleveland, OH  44114 (216) 802-1300 Fax:  (216) 802-1308

                                                                                   File Number: xxx-xx-xxxx

Employee Name:

Employee Name

Address

City, ST ZIP

Dear M ,

This letter is with regard to your claim for benefits under Part E of the Energy Employees Occupational Illness Compensation Program Act (EEOICPA) for the covered condition(s) of XXXXXXXXXX. As a covered Part E worker you may also be eligible for compensation for wage loss resulting from the covered illnesses.

Wage Loss

Wage loss determinations are based on the year(s) of wage loss up to and including the calendar year that an employee reaches normal Social Security retirement age; or year(s) of wage loss up to and including the last calendar year of wage loss prior to the submission of the EEOICPA claim, which ever occurs first. To support your claim for wage loss the following information is required:

1. The dates/periods (s) of wage loss and identify the first quarter you began losing wages as a result of the covered illness(es). Please identify the first day of lost wages from work.

2. Evidence of wages three years prior to that first day of wage loss

3. Medical evidence supporting a causal relationship between the covered illness(es) and the wage loss claimed.

Enclosed is Form SSA-581. Please complete the form and return it to the address above, if you prefer that the Department of Labor obtain your Social Security Administration Earnings records to assist with the wage loss process. In addition to the SSA-581 you can provide tax returns, pay stubs, union records and pension records to help support covered Part E employee’s wages.

Please submit the requested information within 30 days of the date of this letter.

If you have any questions regarding this letter please call toll-free (Insert Toll Free Number).

Sincerely,

Claims Examiner

Enclosure

U.S. DEPARTMENT OF LABOR

EMPLOYMENT STANDARDS ADMINISTRATION OFFICE OF WORKERS' COMPENSATION PROGRAMS DIVISION OF ENERGY EMPLOYEES' COMPENSATION 400 WEST BAY ST, ROOM 722                                                                                   JACKSONVILLE FL 32202 PHONE: (904) 357-4705; TOLL FREE: 1- (877) 336-4272

File:

Employee:

Dear M :

This letter is in reference to your claim for benefits under Part E of the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).

Based on a review of your file, you may be eligible for wage loss and/or impairment benefits as a result of the following accepted covered illness(es):

In order to make a determination for entitlement to wage loss, please provide a signed written response that includes the following:

· An indication whether you would like to claim wage loss;

· The month and year you first experienced wage loss as a result of the accepted covered illness(es).

· The earnings and medical documentation to support the period of wage loss being claimed as discussed below.

Earnings: For proof of wage loss, we need records of your earnings 3 years prior to when you first experienced wage loss to the present. To assist us in this effort, you may submit any legible copies of trustworthy earnings records for this period of time. This includes, but may not be limited to:

· Social Security Earnings Records

· Social Security Disability Benefits Statements

· Tax Returns

· Pay Stubs

· Union Records

· Pension Records

To assist you, we will also attempt to obtain your social security earnings records. Please complete and sign the attached Form SSA-581 and send to our office.

Medical: In addition, you must provide medical evidence establishing a causal relationship between the accepted covered illness(es) and when you first experienced wage loss. Examples of this may include:

• Medical reports or doctor’s notes showing you were unable to work as a result of one of the above accepted covered illnesses;
• Return to work slips signed by a doctor;
• A doctor’s signed statement explaining the causal relationship between the accepted covered illness(es) and the period(s) of wage loss

Impairment:

If you believe that you have reached maximum medical improvement (MMI) as a result of the above accepted condition(s) or your condition(s) is/are terminal, you may be eligible for impairment benefits. To do so, you need to submit a signed statement indicating whether you wish to file a claim for impairment benefits.

Please submit the above requested information within 30 days from the date of this letter.

If you have any questions or concerns regarding what to submit for earnings or medical documents for wage loss, please contact (Insert Name) toll free at: (Insert Toll Free Number). 

Sincerely,

Claims Examiner

Enclosure: SSA-581