EC Code Justification Memo

Employee Name: _______________ SSN: _______________

Claimant Name(s)(if other than employee: ______________

Response to employment verification requests are no longer required based on the following criteria:

______ ORISE verification received

______ DOE employment verification received

______ Corporate verification received

______ Social Security verification received

______ Rec. Decision–Deny –

______ Medical evidence insufficient

______ Employment evidence insufficient

______ Survivor evidence insufficient

______ Other: ______________________________________

_______________________________________

Claims Examiner: ___________________ Date: _________