EEOICP Forms for Federal Government

Date

STATE WORKERS’ COMPENSATION AGENCY

STREET ADDRESS

CITY, STATE ZIP CODE

The information requested in the attachments is required in connection with claims for benefits under the Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. § 7384 et seq. Section § 7385s-11 of the EEOICPA provides for coordination of benefits with respect to state workers’ compensation as follows:

(a) IN GENERAL.—An individual who has been awarded compensation under this part, and who has also received benefits from a State workers’ compensation system by reason of the same covered illness, shall receive compensation specified in this part reduced by the amount of any workers’ compensation benefits, other than medical benefits and benefits for vocational rehabilitation, that the individual has received under the State workers’ compensation system by reason of the covered illness, after deducting the reasonable costs, as determined by the Secretary, of obtaining those benefits under the State workers’ compensation system.

* * *

(c) INFORMATION.—Notwithstanding any other provision of law, each State workers’ compensation authority shall, upon request of the Secretary, provide to the Secretary on a quarterly basis information concerning workers’ compensation benefits received by any covered DOE contractor employee entitled to compensation or benefits under this part, which shall include the name, Social Security number, and nature and amount of workers’ compensation benefits for each such employee for which the request was made.

OMB Control No. 1240-0002 EE-13

Expiration Date: XX/XX/XXXX November 2009

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The first attached list contains the names of employees who worked at facilities in your state on whose behalf a claim under

Part E of EEOICPA has been accepted during the last year. The second list contains the names of employees for whom we have made a previous inquiry. For each employee, we have listed the name(s) of the claimant(s), whether the claimant is the employee or a survivor, the Social Security Number of the employee, the accepted condition, and the date eligibility began. For each entry on the first list, please indicate whether or not a state workers’ compensation claim has been filed on behalf of that same worker, the name(s) of the claimant, and whether the claim has been accepted, and if accepted, the accepted condition, the effective date of the award, and the amount of the award. For each entry on the second list, please indicate whether there has been any change since the last time information was provided.

If you have questions about this request, please contact XXXXXXX XXXXXXXX at (111) 222-3333.

Sincerely,

Rachel P. Leiton

Director, Division of Energy Employees Occupational Illness Compensation

Enclosure: EN-13

OMB Control No. 1240-0002 EE-13

Expiration Date: XX/XX/XXXX November 2009

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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 given to the Federal agencies or private entities that employed the employee to verify statements made, answer questions concerning the status of the claim and to consider other relevant matters. (4) 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. (5) Information may be given to Federal, state, and local agencies for law enforcement purposes, to obtain information relevant to a decision under EEOICPA, to determine whether benefits are being paid properly, including whether prohibited payments have been made, and, where appropriate, to pursue debt collection actions required or permitted by the Debt Collection Act.

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 16 hours 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 mandatory (42 USC 7385s-11(c)). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, 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-13. Do not submit the completed form to this address.

OMB Control No. 1240-0002 EE-13

Expiration Date: XX/XX/XXXX November 2009

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Employee Name Claimant Name E or S Employee SSN Accepted Condition Effective Date

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