Case ID:

Employee Name:





Dear Mr./Ms. :


This is regarding your claim for benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). On Date of Letter or Phone Call you advised us that you do not want to pursue a claim for wage-loss.


I would like to thank you for taking the time to consider our request to file for benefits. Please note that your decision at this time does not relinquish your right to file a claim for wage-loss in the future. Therefore, we will not undertake further development for wage-loss at this time. Should you wish to pursue a claim in the future, please notify us in writing at the address above.


If you have any questions about your claim 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