EEOICPA Forms

These forms are for education only.  Please remember that DOL changes forms without providing notice to the public and you will need to contact DOL for the most current forms.

Commonly Used Forms

• Authorization to Obtain Earnings Data from the
  Social Security Administration
• EE-1 Employee Claim Application
• EE-2 Survivor Claim Application 
• EE-3 Worker's Employment History
• EE-4 Form for Verifying the Employment History of Someone Other than Yourself  
• EE-7 Medical Requirements under the EEOICPA
• Employment Verification form
•  EE-8 Smoking History Request form
• EE/EN-9 Racial/Ethnic Identification under EEOICPA
• EE-10 Claim for Additional Wage-Loss and/or
  Impairment Benefits Under the EEOICPA
• EE-11a Impairment Benefits Response Form
• EE-11b Wage-Loss Benefits Response Form
• EE/EN-12
• EE/EN-16
• Medical Requirements for Proving an Illness
• OCAS-1 Claimant Statement that NIOSH has been provided with All Information Claimant's Possesses 
• OWCP-04 Billing form for Medical Expenses
• OWCP-1500 Health Insurance Claim form
• OWCP-957 Medical Travel Refund Request form
• OWCP-915 Reimbursement for Medical Expenses for an Accepted Illness

Other useful forms

• Authorization to Obtain Earnings Data from Social Security Administration form
• Authorized Representative form
• Claim for Additional Wage Loss or Impairment form
• DEEOIC Case Transfer Sheet
• OWCP-20 Overpayment Recovery Questionnaire
• Employment Response Report
• Employment Verification Referral form
• Expedited Case for Terminally Ill Claimant
• Freedom of Information Act Request form Privacy Act Record System Log of Disclosures form
• Form used to refer Claim to NIOSH
• Ethnicity Request form
• Instruction Form used to refer Claim to NIOSH
• Part E Wage Loss Worksheet # 1
• Part E Wage Loss Worksheet # 2
• Part E Wage Loss Worksheet # 3
• Payment Information form-ACH Vendor Payment System
• Payment Transaction form
• Payment Transaction form for Exception Processing
• Payment Cancelation form
• Potential Provider letter
• Provider Enrollment form
• SEC Class Screening Worksheet
• Workers’ Compensation Claims form Acceptance of Payment form