EEOICP Forms for Individuals or Households

Energy Employees Occupational Illness Compensation Program Act Forms

OMB: 1240-0002

IC ID: 13934

Documents and Forms

Document Name Document Type
Form EE-1 English EEOICP Forms for Individuals or Households Form and Instruction
EE-1 English Worker's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act EE 1.pdf www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms Form and Instruction
EE-2 English Survivor's Claim for Benefits Under the Energy Employees Occupational Illness Compensation Program Act EE 2.pdf www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms Form and Instruction
EE-3 English Employment History for a Claim Under The Energy Employees Occupational Illness Compensation Program Act EE 3.pdf www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms Form and Instruction
Form EE-8 Letter to Claimant EE-8 .2024.pdf Form
EE-9 Letter to Claimant EE-9 .2024.pdf Form
EE-10 Letter to Claimant EE-10-2024.pdf Form
EE-20 Letter to Claimant EE-20.2024.pdf Form and Instruction
EE-12 Letter to Claimant EE-12.2024.pdf Form
EE-16 and EN-16 Letter to Claimant EN-16.2024.pdf Form
EE-17A CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR ASSISTED LIVING BENEFITS UNDER THE ENERGY EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION PROGRAM ACT EE-17A.6.24.2024.pdf Form and Instruction
EE-13 Letter to State Workers Compensation Authorities EE EN 13.pdf Form and Instruction
EE-17B Physician's Certification of Necessity Under the EEOICPA EE-17B.pdf eclaimant.dol.gov Form and Instruction
EE-4 English Employment History Affidavit for a Claim under the EEOICPA EE 4.pdf www.dol.gov/ agencies/owcp/energy/regs/compliance/claim_forms Form and Instruction
EE-4 Employment History Affidavit for a Claim under the EEOICPA EE-4.2024.pdf www.dol.gov/agencies/owcp/energy/regs/compliance/claim_forms Form and Instruction
EE-4 Spanish Declaración jurada sobre historial de empleo para reclamación según la Ley del Programa de Indemnización por Enfermedades Ocupacionales para Empleados del Sector de la Energía EE-4-Spa_ES.2024.pdf eclaimant.dol.gov Form and Instruction