OMB control number
Claim for Consequential Illness Benefits Under the Energy Employees Occupational Illness Compensation Program Act
OMB 1240-0063 · DOL/OWCP.
OMB 1240-0063
Form EE-1A, Claim for Consequential Illness Benefits Under the Energy Employees Occupational Illness Compensation Program Act, will be used to initiate claims for consequential illnesses under the Act. It requests information about the employee/claimant, the specific medical diagnoses that they claim as consequential illness(es), and previous awards or settlements received in connection with the claimed consequential illnesses.
The latest form for Claim for Consequential Illness Benefits Under the Energy Employees Occupational Illness Compensation Program Act expires 2027-07-31 and is listed under ICR 202405-1240-001.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form EE-1 Claim for Consequential Illness Benefits under the Employees Occupational Illness Compensation Program Act | Form and Instruction |
| 1240-0NEW_Supporting Statement_DEEOIC Consequential Illness Form (EE1-A)_FINAL.docx | Supporting Statement A |
 Claim for Consequential Illness Benefits under the Employees Occupational Illness Compensation Program Act |
Form and Instruction |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202405-1240-001 | New collection (Request for a new OMB Control Number) | 2024-05-29 | Approved with change |