Survivor's Claim

• Legal Form Number: EE-2
• Issuer: Office of Workers' Compensation Programs - Division of Energy Employees Occupational Illness Compensation
• Section: U.S. Department of Labor

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

Year DayMonth

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

Reset Form

Print Form

Save Form

Next Page