EE-10 Claim for Additional Wage-Loss and/or Impairment Under t

Claim for Additional Wage-Loss and/or
Impairment Under the Energy Employees
Occupational Illness Compensation Program Act

U.S. Department of Labor

Employment Standards Administration
Office of Workers’ Compensation Programs
OMB No. 1215-0197
Expiration Date: 08/31/2007

Note: Provide all information requested below. Do not write in the shaded areas.

Employee’s Information (print clearly)

Submit

Reset

Print

1. Name (Last, First, Middle Initial)

2. Social Security Number

3. Address (Street, Apt. #, P.O. Box)

4. Telephone Number(s)
a. Home:

(

)

-

b. Other:

(

)

-

(City, State, ZIP Code)

ı–

Compensation is Claimed for: (Check one or both boxes and provide the requested information)

Wage Loss – Claims for additional wage loss may only be submitted if at least one year has elapsed
since you were awarded compensation for wage loss, and can only be claimed in calendar year
increments. Multiple years can be claimed as long as it has been one (1) year since the previous
award for wage loss. However, this claim form may not be used to claim for prior years of wage loss
that have already been rejected.
Indicate the calendar year(s) wage loss was sustained and provide the gross earnings for
each year claimed. DO NOT list any years in which OWCP either paid or denied
compensation for wage loss.
1.

Calendar Year of Wage Loss:

Total Gross Earnings:

$

2.

Calendar Year of Wage Loss:

Total Gross Earnings:

$

3.

Calendar Year of Wage Loss:

Total Gross Earnings:

$

4.

Calendar Year of Wage Loss:

Total Gross Earnings:

$

5.

Calendar Year of Wage Loss:

Total Gross Earnings:

$

Increased Impairment Rating – Claims for an increased permanent impairment rating may only
be submitted if at least two (2) years has elapsed since you were last awarded impairment benefits.

Provide the increase in impairment since the last award of impairment benefits.
Increase in Impairment

%

Declaration of the Person Completing this Form
Any person who knowingly makes any false statement, misrepresentation, concealment of fact of
any other act of fraud to obtain compensation as provided under EEOICPA or who knowingly
accepts compensation to which that person is not entitled is subject to civil or administrative
remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be
punished by a fine or imprisonment or both. In addition, a felony conviction will result in
termination of all current and future EEOICP benefits. I affirm that the information provided on
this form is accurate and true.

(Signature)

Resource Center Date Stamp

(Date)
Form EE-10
April 2005

Next Page

Instructions for Completing Form EE-10
This form is used by employees to claim additional wage loss and/or impairment rating for a claim filed under the Energy
Employees Occupational Illness Compensation Program Act (EEOICPA). The employee must claim for an additional year(s)
of wage loss, for increased impairment rating, or both. Both claims must be supported by sufficient evidence to establish
that the claimant is entitled to the benefits claimed.
Wage Loss - Claims for additional wage loss may only be submitted by employees and only if at least one year has
elapsed since any previous awarded compensation for wage loss, and can only be claimed in calendar year increments.
Multiple years can be claimed as long as it has been one (1) year since the previous award for wage loss. However,
this claim form may not be used to claim for prior years of wage loss that have already been rejected. Any claim for
wage loss must be supported by sufficient factual and medical evidence of another calendar year of compensable wage
loss.
• Calendar Year of Wage Loss: A calendar year is defined as the twelve-month period from January through
December. Do not list days or months; just the calendar year(s).
• Total Gross Earnings: Show the total wages earned, before any payroll deductions, during the claimed
calendar year.
Increased Impairment Rating - Claims for an increased permanent impairment rating may only be submitted by
employees and only if at least two (2) years has elapsed since the last awarded impairment benefits. Any claim for
increased impairment rating must be supported by medical evidence of an increased minimum impairment rating due to
a covered illness or illnesses. The employee must provide the percentage increase in impairment since the last award of
impairment benefits, and supporting medical documentation.

Privacy Act
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 U.S.C. 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 which the Office has 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 given to the Federal agencies or private entities that employed the claimant at the time of
injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to consider
other relevant matters. (4) Information may be disclosed to physicians and other health care providers for use in providing
treatment or medical rehabilitation, making evaluations for the Office of Workers’ Compensation Programs and for other
purposes related to the medical management of the claim. (5) Information may be given to Federal, state, and local agencies
for law enforcement purposes, to obtain information relevant to a decision under the EEOICPA, to determine whether benefits
are being paid properly, including whether prohibited payments have been made, and, where appropriate, to pursue
salary/administrative offset and debt collection actions required or permitted by the Debt Collection Act. (6) Disclosure of the
claimant's social security number (SSN) or tax identification number (TIN) is mandatory. The SSN or TIN, and other
information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the
Federal government, and for other purposes required or authorized by law. (7) 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
Public reporting burden for this collection of information is estimated to average five (5) minutes per response, including
time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing
the collection of information. If you have any comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, send them to the Office of Workers’ Compensation
Programs, U.S. Department of Labor, Room S3524, 200 Constitution Avenue, N.W., Washington, D.C. 20210. Do not
submit the completed claim form to this address. Completed claims are to be submitted to the appropriate district
office of the Office of Workers’ Compensation Programs. Persons are not required to respond to the information collections
on this form unless it displays a currently valid OMB number.

Form EE-10
April 2005

Prev Page