Claim for Additional Wage-Loss and/or Impairment Under the Energy Employees Occupational Illness Compensation Program Act

U.S. Department of Labor Employment Standards Administration Office of Workers’ Compensation Programs

Note:  Provide all information requested below.  Do not write in the shaded areas.

OMB No. 1215-0197 Expiration Date:

Employee’s Information  (print clearly)

1.  Name (Last, First, Middle Initial)

2.  Social Security Number

3.  Address  (Street, Apt. #, P.O. Box)

4.  Telephone Number(s)

a.  Home: (        )                     -

(City, State, ZIP Code)

b.  Other: (        )                    -

Compensation is Claimed for: (Check one or both boxes and provide the requested information)

Wage Loss – Claims for additional wage loss may only be submitted if at least one year has elapsed since you were awarded compensation for wage loss, and can only be claimed in calendar year increments.  Multiple years can be claimed as long as it has been one (1) year since the previous award for wage loss.  However, this claim form may not be used to claim for prior years of wage loss that have already been rejected.  Indicate the calendar year(s) wage loss was sustained and provide the gross earnings for each year claimed.  DO NOT list any years in which OWCP either paid or denied compensation for wage loss.

1.

Calendar Year of Wage Loss:

Total Gross Earnings:

$

2.

Calendar Year of Wage Loss:

Total Gross Earnings:

$

3.

Calendar Year of Wage Loss:

Total Gross Earnings:

$

4.

Calendar Year of Wage Loss:

Total Gross Earnings:

$

5.

Calendar Year of Wage Loss:

Total Gross Earnings:

$

Increased Impairment Rating – Claims for an increased permanent impairment rating may only be submitted if at least two (2) years has elapsed since you were last awarded impairment benefits. Provide the increase in impairment since the last award of impairment benefits.

Increase in Impairment

%

Declaration of the Person Completing this Form

Any person who knowingly makes any false statement, misrepresentation, concealment of fact of 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.  In addition, a felony conviction will result in termination of all current and future EEOICP benefits.  I affirm that the information provided on this form is accurate and true.

Resource Center Date Stamp

(Signature)

(Date)

Form EE-10 April 2005