Sample Partial Accept/Partial Denial Bifurcated Waiver

                                     

     File Number:

              Employee:

              Claimant:

              Date of Decision:

Final Adjudication Branch

U.S. Department of Labor, DEEOIC

FAB Street Address

City, State, ZIP

 

Dear Sir or Madam:                File Number:

 

(Option 1)

 

I, ____________________, being fully informed of my right to object to any of the findings of fact and/or conclusions of law contained in the Recommended Decision issued on my claim for compensation under the Energy Employees Occupational Illness Compensation Program Act, do hereby waive those rights only as those rights pertain to the portion of my claim recommended for acceptance.  I do, however, reserve my right to object to the findings of fact and/or conclusions of law contained in the Recommended Decision that recommend denial of claimed benefits. 

 

I understand that should I choose to file an objection, I may either attach such objection to this form or submit a separate written objection to the address listed above within 60 days of the date of issuance of the Recommended Decision.

 

_______________________                   

Signature                    Date

 

(Option 2)

 

I, ____________________, being fully informed of my right to object to any of the findings of fact and/or conclusions of law contained in the Recommended Decision issued on my claim for compensation under the Energy Employees Occupational Illness Compensation Program Act, do hereby waive those rights.

 

_______________________                   

Signature                    Date


 

(NOTE ON WAIVER:  If you wish to file a waiver of objections, please select and sign only one of the above options.  Select Option 1 to waive your right to object to the portion of your claim recommended for acceptance but reserve your right to object to the recommended denial of benefits.  Select the Option 2 to waive your rights to object to ALL findings and conclusions.)