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.



File Number:       






Dear Mr./Ms.      :


On       and again on      , I sent you letters asking if you would like to file a claim for wage-loss benefits.  As of this date, I have not received a response from you.


I would like to thank you for taking the time to consider our request to file for benefits.  Your decision not to respond at this time does not relinquish your right to file a claim for wage-loss benefits in the future; therefore, I will put this issue on hold until further notice from you. 


If at anytime you would like to pursue wage-loss benefits or if you would like to discuss this issue further or other benefits available under this program, do not hesitate to call me toll-free, at      .  If it is more convenient, you may visit one of our local resource centers for additional help. 







Claims Examiner