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 Form EE-10

Expiration Date: 05/31/2025 September 2021

Page 1

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:

Dear

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

Compensation Program Act (EEOICPA). 

Our records indicate that you received a prior award under Part E of EEOICPA for impairment and/or wageloss as a result of an accepted work-related illness. The rules governing the administration of the Energy 

program allow for an individual to seek additional benefits after a certain period of time has elapsed since a 

prior award of benefits. The attached EN-10 is used to claim those additional benefits. However, to claim 

additional benefits using the EN-10, you must be aware of the following:

WAGE-LOSS – A claim for additional wage-loss benefits may only be submitted if at least one year has 

elapsed since you were previously awarded benefits for wage-loss in a final decision. In addition, 

eligibility is based on qualifying wage-loss sustained in calendar year increments as a result of the accepted 

illness. If you claim for additional wage-loss benefits due to an accepted illness, development will be 

initiated to obtain the evidence necessary to show that you have sustained additional wage-loss due to your 

accepted illness. This will include obtaining financial and medical documentation from you in support of 

the claim. You cannot seek benefits for calendar years of wage-loss that have been addressed previously 

by a final decision. 

IMPAIRMENT – A claim for increased permanent impairment benefits may only be submitted if at least

two years has elapsed since you were last awarded impairment benefits in a final decision. If you claim for 

additional impairment benefits, development will commence to determine the extent to which your 

accepted illness has resulted in an increased permanent impairment of the whole body. This will require a 

medical examination by an appropriate physician, and a review of up-to-date medical documentation. 

The attached EN-10 should be completed only if you are pursuing additional wage-loss or impairment benefits

and can obtain the evidence necessary to establish your claim. You may claim additional wage-loss and 

impairment at the same time. If you choose to file for additional benefits, mail the enclosed EN-10 to the 

following address:

U.S. Department of Labor

OWCP/DEEOIC

P.O. Box 8306

London, KY 40742-8306

Name 

Address 

City, State, Zip
OMB Control No: 1240-0002 Form EE-10 

Expiration Date: 05/31/2025 September 2021 

Page 2 

If you are not interested in filing a claim for additional benefits at this time, take no action with regard to this 

letter. Should you have questions about completing the EN-10, please contact your district office at 

Sincerely, 

Enclosure: EN-10 

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 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. The obligation to respond to this collection is required to obtain EEOICPA 

benefits (20 CFR 30.102). 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-10. Do not submit the completed form to this address. 

Name 

Title 

Office
OMB Control No: 1240-0002 Form EN-10 

Expiration Date: 05/31/2025 September 2021 

Claim for Additional Wage-Loss and/or 

Impairment Benefits Under the Energy 

Employees Occupational Illness Compensation 

Program Act 

U.S. Department of Labor 

Office of Workers’ Compensation Programs 

Division of Energy Employees Occupational 

 Illness Compensation

Note: Please review all instruction relating to this form before completing. 

Sign and date the bottom of the page. 

OMB Control No: 1240-0002 

Expiration Date: 05/31/2025 

Employee’s Information (print clearly)

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) 

Additional Compensation Claimed: (check one or both boxes)

Wage-Loss – I hereby claim additional wage-loss benefits as a result of my accepted work-related 

illness. It has been at least one year from the date of a prior final decision awarding me wage-loss 

benefits. As a result of this claim, I realize that I will be expected to provide the evidence necessary to 

support that I have sustained additional wage-loss in one or more calendar year(s). My claim does not 

include years of wage-loss addressed by a previous final decision. 

Impairment – I hereby claim increased permanent impairment benefits as a result of my accepted 

work-related illness. It has been at least two years from the date of a prior final decision awarding me 

benefits based on a percentage of whole person impairment. As a result of this claim, I realize that I will 

be expected to provide medical evidence that supports an increased impairment. This may include 

obtaining updated diagnostic evidence, along with an updated medical examination by an appropriate 

physician. 

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 EEOICPA benefits. I affirm that 

the information provided on this form is accurate and true. 

(Signature) (Date) 

Resource Center Date Stamp