Sample Partial Accept/Partial Denial Bifurcated Waiver

Case Number:

Employee:

Claimant:

Date of Decision:

U.S. Department of Labor, DEEOIC

Attn: Final Adjudication Branch

P.O. Box 8306

London, KY 40742-8306

Dear Sir or Madam:

(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.)