Form EE-2 

September 2021

U.S. Department of Labor Office of Workers’ Compensation Programs 

Division of Energy Employees Occupational 

Illness Compensation

Survivor's Claim for Benefits Under the Energy 

Employees Occupational Illness Compensation Program 

Act

Note: Please read the instructions on page 3 before filling out this form. Provide all information 

requested, and sign and date the bottom of page 2. Do not write in the shaded areas.

OMB Control No: 1240-0002 

Expiration Date: 05/31/2025

Deceased Employee Information (Please Print Clearly)

1. Name (Last, First, Middle Initial) 3. Social Security Number

4. Date of Birth

Month Day Year

2. Sex

 Male Female

6. Was an autopsy performed on the employee?

 Yes - List Medical Facility:

 No Don't Know

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

(City, State, ZIP Code)

13. Telephone Number(s)

a. Home: ( )

b. Other: ( ) -

-

14. Identify the Diagnosed Condition(s) Being Claimed as Work-Related (check box and list specific diagnosis)

Cancer (List Specific Diagnosis Below) 15. Date of Diagnosis

Month Day Year

 a.

 b.

 c.

 d.

Chronic Beryllium Disease (CBD)

Chronic Silicosis

Other Work-Related Condition(s) due to exposure to toxic substances or radiation (List Specific Diagnosis Below)

 a.

 b.

 c.

 d.

Awards and Other Information

16. Have you or the deceased employee filed a lawsuit based on exposure to radiation, beryllium, asbestos or any 

 other toxic substance?

17. Have you or the deceased employee filed any state workers’ compensation claims in connection with any 

 condition(s) you claim in Item 14?

18. Have you, the deceased employee, or another person received a settlement or other award in connection with a 

 lawsuit or state workers’ compensation claim described in questions 16 or 17?

19. Have you either pled guilty to or been convicted on any charges connected with an application for or receipt of 

 federal or state workers’ compensation?

20. Have you or the employee applied for an award under Section 5 of the Radiation Exposure Compensation Act 

 (RECA)?

21. Have you or the employee applied for an award under Section 4 of RECA?

 If yes, provide RECA Claim #:

 Yes No

 Yes No

 Yes No

 Yes No

 Yes No

 Yes No

5. Date of Death

Month Day Year

Survivor Information (Please Print Clearly)

7. Name (Last, First, Middle Initial) 9. Social Security Number 8. Sex

 Male Female

10. Date of Birth

Month Day Year

11. Your relationship to the deceased employee

 spouse

 parent

 child

 grandparent

 step-child

 grandchild

 adopted child

 other:

Page 1 of 3
Form EE-2 

September 2021

Survivor Declaration

Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or 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. Any change to the information provided on this form once it is submitted must be reported immediately to the district 

office responsible for the administration of the claim. I hereby make a claim for benefits under EEOICPA and affirm that the information I have 

provided on this form is true. If applicable, I authorize the Department of Justice to release any requested information, including information 

related to my RECA claim, to the U.S. Department of Labor, Office of Workers’ Compensation Programs (OWCP). Furthermore, I authorize any 

physician or hospital (or any other person, institution, corporation, or government agency, including the Social Security Administration) to 

furnish any desired information to the U.S. Department of Labor, Office of Workers’ Compensation Programs.

Claimant Signature Date 

Other Potential Survivors

22. List any person(s) who may also qualify as a survivor of the deceased employee and include the following information:

 Name Relationship to the 

 deceased employee Address Phone Numbers

 a.

Home:

Other:

 b.

Home:

Other:

 c.

Home:

Other:

 d.

Home:

Other:

 e.

Home:

Other:

 f.

Home:

Other:

 g.

Home:

Other:

 h.

Home:

Other:

 i.

Home:

Other:

 j.

Home:

Other:

Page 2 of 3
Form EE-2 

September 2021

Instructions for Completing Form EE-2

Complete all items on the form. If additional space is required to explain or clarify any point, attach a supplemental statement to the form. If the 

requested information is not submitted, you should explain the reason(s) for the delay and indicate when the information will be forthcoming. 

Submit the completed claim form and all other pertinent documentation to the following address: 

U.S. Department of Labor 

OWCP/DEEOIC 

P.O. Box 8306 

London, KY 40742-8306 

Deceased Employee Information 

Item 14 – Identify the employee’s physician-diagnosed condition(s) that you claim are work related. Do not list the symptoms 

(e.g. aches, pains, cough, wheezing, breathing problems, etc.) associated with the diagnosed condition(s). Attach to the claim form 

any pertinent medical documentation and copy of the employee’s death certificate. If you require additional space, attach a 

signed supplemental statement to this form. 

Item 15 – List the date a physician first diagnosed the claimed condition(s). 

Awards and Other Information 

Question 16 - Mark the appropriate box indicating whether you or the deceased employee filed a civil lawsuit based on exposure to any 

toxic substance. If you mark the box for YES, provide copies of all pertinent court documentation. 

Question 17 - Mark the appropriate box indicating whether you or the deceased employee filed any state workers' compensation claims 

related to any condition(s) you claim in Item 14. If you mark the box for YES, provide copies of all state workers' compensation 

documentation. 

Question 18 - Mark the appropriate box indicating whether you, the deceased employee or another person received a settlement or other 

award for a lawsuit or a state workers' compensation claim described in Questions 16 or 17. If you mark the box for YES, provide copies of 

all pertinent documentation. 

Question 19 - Mark the appropriate box indicating whether or not you have ever pled guilty to or been convicted on any charges 

connected to an application for or receipt of federal or state workers' compensation. 

Question 20 - Mark the appropriate box indicating whether you or the deceased employee filed for an award from the Department of 

Justice (DOJ) under Section 5 of the Radiation Exposure Compensation Act (RECA). If you mark the box for YES, provide the claim 

number associated with that RECA claim in the space provided. 

Question 21 - Mark the appropriate box indicating whether you or the deceased employee filed for an award from DOJ under Section 4 of 

RECA. 

Other Potential Survivors 

Question 22 – Every eligible survivor of a covered employee must be identified prior to the payment of any compensation. 

List any individual who may also qualify as a survivor of the deceased employee and provide the additional information requested in 

this item, if known. Under EEOICPA, certain limitations apply to the definition of persons who may qualify as an eligible survivor. 

Eligible survivors of a deceased employee may include his or her: surviving spouse, child (biological, step or adopted), parent, 

grandchild, or grandparent. Any claim for survivor benefits must be accompanied by proof of relationship to the deceased employee. 

This includes, but may not be limited to, a copy of a marriage certificate, birth certificate, or adoption papers.

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. (6) Disclosure of your social security number (SSN) or tax identification number (TIN) is mandatory. We are authorized to 

collect your SSN or TIN under Executive Order 9397 (November 22, 1943). Your 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

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 17 minutes per 

response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and 

reviewing the collection of information. You are required to respond to this collection to obtain EEOICPA benefits (20 CFR 30.100(a)). 

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-2. Do not submit the completed form to this 

address.

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