U.S. Department of Labor

Employment Standards Administration

Office Of Workers’ Compensation Programs

Division of Energy Employees’ Compensation

DO Address

City, State  ZIP

Phone: DO Phone No.

Fax:     DO FAX No.


Date:                                                               File Number:       


2nd Inquiry - 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).  On      , I wrote to you outlining wage-loss benefits that you might be entitled to due to your covered illness(es).  I have not heard from you so please let me recap your potential benefits.


Wage- Loss:  Wage-loss compensation is awarded if an employee’s loss of earnings was caused by his/her covered illness.  Wage-loss compensation is payable for only years before normal Social Security Administration retirement age; usually 65 years of age (see chart to find your normal retirement age).


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 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
  • Pay Stubs
  • Social Security disability records
  • Union Records
  • Tax Returns
  • 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 I do not hear from you by      , I will assume you are not interested in filing for wage-loss benefits at this time and I will suspend development of your wage-loss claim until further notice from you.  If you have any questions about your claim or wage-loss in general you may contact me toll free at 1-(     )-     -     . 







Claims Examiner


Enclosure: SSA-581

Pamphlet, “Wage- Loss Benefits”

Social Security Retirement Age Table