U.S. Department of Labor

Employment Standards Administration

Office Of Workers’ Compensation Programs

Division of Energy Employees’ Compensation

DO Address

City, State  Zip

Phone: (xxx) xxx-xxxx or (xxx) xxx-xxxx

Fax:     (xxx) xxx-xxxx


 Date:                                                         File Number:       


Response requested





Dear Ms./Mr.     :


I am writing in regards to your claim for employee benefits under Part E of the Energy Employees’ Occupational Illness Compensation Program Act (EEOICPA).  Your claim has been accepted for the following covered illness(es):       .  Therefore, you may now be eligible for wage-loss benefits due to your covered illness(es).


Wage - Loss:  Wage-loss compensation is awarded if 1) an employee’s loss of earnings was caused by his/her covered illness and 2) is payable for only the years of wage-loss experienced before normal Social Security Administration retirement age; usually 65 years of age (see enclosed chart to find your normal retirement age).  We have also provided a brochure that provides additional information on how wage-loss awards are calculated. 


Based on the above criteria, if you believe you would qualify and you wish to file for wage-loss benefits, this is what we will need from you to make a determination for an 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 and last 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 12 quarters (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 statements

·        Social Security disability records

·        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 return it to our office.  It is very important that you return the SSA-581 Form signed and completed in order for our office to request and obtain your earnings records.  This form is time sensitive; please sign and return to our office as soon as possible.


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



Please submit the requested information to our office by      .  If you need additional time to obtain and submit the information, please call me as soon as you can to discuss an extension.  You may contact me toll free at 1-(     )-      -     . 







Claims Examiner


Enclosure: SSA-581

Pamphlet, “Wage- Loss Benefits”

Social Security Retirement Age Table