RC Checklist Cover Sheet

Date: _______________

To:

DOL Jacksonville District Office

Attention:

__________________

DOL Denver District Office

 

 

DOL Cleveland District Office

 

 

DOL Seattle District Office

 

 

 

The attached claim forms are submitted with supporting documentation.

Employee: ________________________ SSN: ________________________

Survivor: _________________________ SSN: ________________________

 

Enclosed documents include:

 

EE-1/EE-2

Birth Certificate

EE-3

Marriage License/Certificate

EE-4

Death Certificate

Authorization for Representation

Divorce Decree

EE-5 (s)

Power of Attorney Document

ORISE Printout

Adoption Records

Copy - Appendix H or 02-34 letter

SSA-581

Copy - Letter to DOE OPS Center

Social Security Records (brought in by claimant)

Copy Letter to Corporate Verifier

Medical Records/Pathology Report

Claimant Employment Records

Other

Occupational History Questionnaire

Other

Occupational History Thank You Letter

Other

 

Resource Center Manager ________________________________