EE-11B/EN-11B: Wage Loss Letter & Response Form

Date:

Case ID Number:
Response requested

Name
Street Address
City, State ZIP

First Request
Second Request
Final Request

Dear :
This letter is in regard to your claim under Part E of the Energy Employees Occupational
Illness Compensation Program Act (EEOICPA). Your claim has been accepted for the
following illness(es): . As such, you may be eligible for a monetary award for wage-loss
caused by the accepted illness(es).
Wage-Loss: Wage-loss benefits: (1) are awarded if the accepted illness(es) caused or
contributed to an employee’s loss of earnings; and (2) are payable only for the calendar
years of wage-loss experienced before an employee’s normal Social Security retirement
age. A person’s normal retirement age is based on the year when he/she was born and is
usually 65 years of age, but can be as high as 67 years of age (see the enclosed Social
Security Retirement Age Table). Wage-loss benefits are payable only through the
calendar year when normal retirement age is reached.
Based on the above criteria, if you believe you (either as the employee or as the
employee’s survivor) may qualify and wish to file for wage-loss benefits, please
complete the enclosed Form EN-11B (Wage-Loss Benefits Response Form) and be sure
to provide the following information:




Check “YES” to indicate that you are seeking wage-loss benefits.
Enter the month and year {your or the employee’s} initial wage-loss began due to
the accepted illness(es).
Enter the months and years {you or the employee} last experienced wage-loss as a
result of the accepted illness(es).

In addition, earnings and medical documentation must be submitted to support the period
of wage-loss being claimed as discussed below.
_______________________________________________________________________
If you have a disability (a substantially limiting physical or mental impairment), please contact our
office for information about the kinds of help available, such as communication assistance (alternate
formats or sign language interpretation), accommodations and modification.

OMB Control No: 1240-0002
Expiration Date: 03/31/2022

EE-11B
November 2016
Page 1

Earnings: For proof of wage-loss, we need the records of earnings for the 12 quarters
(36 months) prior to the quarter when {you or the employee} first experienced wage-loss.
We also need records of earnings up to the present or when the wage-loss ceased (or
through the year of normal retirement age). To assist us in this effort, you may submit
any legible copies of trustworthy earnings records for this period of time. This includes,
but is not limited to:




Social Security earnings statements
Tax Returns
Union Records





Social Security disability records
Pay Stubs
Pension Records

To help you in this regard, we will also attempt to obtain earnings records from the Social
Security Administration.
Medical: In addition, you must provide medical evidence establishing a causal
relationship between the accepted illness(es) and the wage-loss. Examples of this may
include:




Medical reports or doctor’s notes showing an inability to work as a result of one
of the above accepted illnesses;
Return to work slips signed by a doctor;
A doctor’s report explaining the causal relationship between the accepted
illness(es) and the period(s) of wage-loss. This may include a medically-required
reduction in work-hours or a change to a lower-paying job.

If you elect not to pursue a wage-loss claim at this time, please mark “NO” on Form EN11B and we will not further develop the issue. Also, if this letter is identified above as a
“Final Request” and we do not hear from you, we will also not develop this issue further.
However, you retain the right to pursue a wage-loss claim in the future simply by
notifying us in writing and sending it to the address at the bottom of the enclosed EN11B.
We would appreciate receiving your written response within 30 days. If you have any
questions regarding this letter or wage-loss benefits in general, or you need additional

OMB Control No: 1240-0002
Expiration Date: 03/31/2022

EE-11B
November 2016
Page 2

time to submit the requested information, please do not hesitate to contact me. You may
call me at (xxx) xxx-xxxx.
Sincerely,

Name
Title
Office
Enclosure: Pamphlet, “Wage-Loss Benefits”
Social Security Retirement Age Table
EN-11B

OMB Control No: 1240-0002
Expiration Date: 03/31/2022

EE-11B
November 2016
Page 3

PRIVACY ACT STATEMENT
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby
notified that: (1) The Energy Employees Occupational Illness Compensation Program
Act (42 USC 7384 et seq.) (EEOICPA) is administered by the Office of Workers’
Compensation Programs of the U.S. Department of Labor, which receives and maintains
personal information on claimants and their immediate families. (2) Information
received will be used to determine eligibility for, and the amount of, benefits payable
under EEOICPA, and may be verified through computer matches or other appropriate
means. (3) Information may be disclosed to physicians and other health care providers
for use in providing treatment, performing evaluations for the Office of Workers’
Compensation Programs, and for other purposes related to the medical management of
the claim. (4) Failure to disclose all requested information may delay the processing of
the claim or the payment of benefits, or may result in an unfavorable decision.
PUBLIC BURDEN STATEMENT
According to the Paperwork Reduction Act of 1995, no persons are required to respond
to the information collections on this form unless it displays a valid OMB control
number. Public reporting burden for this collection of information is estimated to
average 30 minutes per response, including time for reviewing instructions, searching
existing data sources, gathering the data needed, and completing and reviewing the
collection of information. The obligation to respond to this collection is required to
obtain EEOICPA benefits (20 CFR 30.505). Send comments regarding the burden
estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, send them to the U.S. Department of Labor, Office of Workers’
Compensation Programs, Room S3524, 200 Constitution Avenue N.W., Washington,
D.C. 20210, and reference OMB Control No. 1240-0002 and Form EE/EN-11B. Do not
submit the completed form to this address.

OMB Control No: 1240-0002
Expiration Date: 03/31/2022

EE-11B
November 2016
Page 4

Case ID Number.
Employee Name:

Wage-Loss Benefits Response Form
YES, I wish to pursue a claim for wage-loss benefits for my accepted illness(es).


The initial wage-loss due to my illness(es) began: _________/__________
(Month/Year)



I am claiming wage-loss due to my accepted illness(es) for the following period:
From: ____/_______(Month/Year) To: ____/_______(Month/Year)

NO, I am not pursuing wage-loss benefits at this time. I understand that I can file for
wage-loss benefits in the future by submitting a signed statement to that effect to the
district office.

Signature (Required)

Signature

Date

Mail form to: U.S. Department of Labor, OWCP/DEEOIC
P.O. Box 34930
San Antonio, TX 78265
Or you may FAX it to: DO FAX Number

OMB Control No: 1240-0002
Expiration Date: 03/31/2022

EN-11B
November 2016