U.S. DEPARTMENT OF LABOR Office of Workers’ Compensation Programs

Division of Energy Employees Occupational 

Illness Compensation 

DOL DEEOIC Central Mail Room

P.O. Box 8306 

London, KY 40742-8306

Case ID Number: 

Response requested

 First Request

 Second Request 

 Final Request 

Dear 

This letter is in regard to your claim under Part E of the Energy Employees Occupational 

Illness Compensation Program Act (EEOICPA). Your claim has been accepted for the 

following illness(es): 

As such, you may be eligible for a monetary award for wage-loss caused by the accepted 

illness(es). 

Wage-Loss: Wage-loss benefits: (1) are awarded if the accepted illness(es) caused or 

contributed to an employee’s loss of earnings; and (2) are payable only for the calendar 

years of wage-loss experienced before an employee’s normal Social Security retirement 

age. A person’s normal retirement age is based on the year when he/she was born and is 

usually 65 years of age, but can be as high as 67 years of age (see the enclosed Social 

Security Retirement Age Table). Wage-loss benefits are payable only through the 

calendar year when normal retirement age is reached. 

Based on the above criteria, if you believe you (either as the employee or as the 

employee’s survivor) may qualify and wish to file for wage-loss benefits, please 

complete the enclosed Form EN-11B (Wage-Loss Benefits Response Form) and be sure 

to provide the following information: 

x Check “YES” to indicate that you are seeking wage-loss benefits. 

x Enter the month and year {your or the employee’s} initial wage-loss began due to 

the accepted illness(es). 

x Enter the months and years {you or the employee} last experienced wage-loss as a 

result of the accepted illness(es). 

In addition, earnings and medical documentation must be submitted to support the period 

of wage-loss being claimed as discussed below. 

_______________________________________________________________________ 

If you have a disability (a substantially limiting physical or mental impairment), please contact our 

office for information about the kinds of help available, such as communication assistance (alternate 

formats or sign language interpretation), accommodations and modification.

OMB Control No: 1240-0002 EE-11B 

Expiration Date: 05/31/2025 September 2021 

Page 1

Name 

Street 

City, State, Zip

 :
Earnings: For proof of wage-loss, we need the records of earnings for the 12 quarters 

(36 months) prior to the quarter when {you or the employee} first experienced wage-loss. 

We also need records of earnings up to the present or when the wage-loss ceased (or 

through the year of normal retirement age). To assist us in this effort, you may submit 

any legible copies of trustworthy earnings records for this period of time. This includes, 

but is not limited to: 

x Social Security earnings statements x Social Security disability records

x Tax Returns x Pay Stubs

x Union Records x Pension Records

To help you in this regard, we will also attempt to obtain earnings records from the Social 

Security Administration. 

Medical: In addition, you must provide medical evidence establishing a causal 

relationship between the accepted illness(es) and the wage-loss. Examples of this may 

include: 

x Medical reports or doctor’s notes showing an inability to work as a result of one

of the above accepted illnesses;

x Return to work slips signed by a doctor;

x A doctor’s report explaining the causal relationship between the accepted

illness(es) and the period(s) of wage-loss. This may include a medically-required

reduction in work-hours or a change to a lower-paying job.

If you elect not to pursue a wage-loss claim at this time, please mark “NO” on Form EN11B and we will not further develop the issue. Also, if this letter is identified above as a 

“Final Request” and we do not hear from you, we will also not develop this issue further. 

However, you retain the right to pursue a wage-loss claim in the future simply by 

notifying us in writing and sending it to the address at the bottom of the enclosed EN11B. 

We would appreciate receiving your written response within 30 days. If you have any 

questions regarding this letter or wage-loss benefits in general, or you need additional 

OMB Control No: 1240-0002 EE-11B 

Expiration Date: 05/31/2025 September 2021 

Page 2 
time to submit the requested information, please do not hesitate to contact me. You may 

call me at 

Sincerely, 

Enclosure: Pamphlet, “Wage-Loss Benefits” 

Social Security Retirement Age Table 

EN-11B 

OMB Control No: 1240-0002 EE-11B 

Expiration Date: 05/31/2025 September 2021 

Page 3 

Name 

Title 

Office
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 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. (4) 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 30 minutes 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 required to 

obtain EEOICPA benefits (20 CFR 30.505). Send comments regarding the burden 

estimate or any other aspect of this collection of information, including suggestions for 

reducing this burden, send them 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-11B. Do not 

submit the completed form to this address. 

 

OMB Control No: 1240-0002 EE-11B 

Expiration Date: 05/31/2025 September 2021 

Page 4 
Case ID Number. 

Employee Name: 

Wage-Loss Benefits Response Form 

 YES, I wish to pursue a claim for wage-loss benefits for my accepted illness(es). 

x The initial wage-loss due to my illness(es) began: _________/__________ 

(Month/Year) 

x I am claiming wage-loss due to my accepted illness(es) for the following period: 

 From: ____/_______(Month/Year) To: ____/_______(Month/Year) 

 NO, I am not pursuing wage-loss benefits at this time. I understand that I can file for 

wage-loss benefits in the future by submitting a signed statement to that effect to the 

district office. 

Signature (Required) 

 

Signature Date 

Mail form to: U.S. Department of Labor 

 OWCP/DEEOIC 

 P.O. Box 8306 

 London, KY 40742-8306 

Or you may FAX it to: 

OMB Control No: 1240-0002 EN-11B 

Expiration Date: 05/31/2025 September 2021