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: _________