U.S.DEPARTMENT OF LABOR      EMPLOYMENT STANDARDS ADMINISTRATION                

                                         OFFICE OF WORKERS’ COMPENSATION PROGRAMS

                                         DIVISION OF ENERGY EMPLOYEES’ OCCUPATIONAL

ILLNESS COMPENSATION

                                         (District Office Address)

 

(Date)

EMPLOYEE NAME:

CLAIM FILE NUMBER:

 

(DAR POC Address)

 

To Whom It May Concern:

 

A claim for benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA) has been submitted with respect to the employee named above, claiming employment at a Department of Energy facility.   He or she is claiming that employment for the Department of Energy or one of its contractors or subcontractors has contributed to a covered illness. Your facility has been identified as having possession of or access to records which may identify employment and toxic substance exposure regarding this individual. 

 

Included as an attachment to this cover letter is a copy of the claimant’s EE-1 or EE-2 Claim for Benefits, the EE-3 Employment History and a Document Acquisition Request (DAR) Questionnaire.  Marked on the attached DAR Questionnaire is the name of the employee, employee SSN, employer name and the facility where employment is alleged to have occurred as well as selected categories of documentation we hope you have at your facility. 

 

Please conduct a reasonable search for the requested documentation and provide a copy of those records in digital PDF format on a compact disc (CD) if available.  You may make as many copies of the DAR Questionnaire as necessary. 

 

Please return the completed DAR Questionnaire, the CD and any hard copy documents to the address provided above.  If you have received this request in error or if you have any other concerns, please feel free to contact me directly at ***-***-**** or fax ***-***-****.

 

Sincerely,

 

 

Claims Examiner

 

Attachments:

 

EE-1/2 Claim for Benefits

EE-3 Employment History