Ee 2 2026

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The document is a form from the U.S. Department of Labor for survivors to claim benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). It requires detailed information about the deceased employee, their diagnosed work-related conditions, and the survivor's relationship to the deceased. The form also includes sections for additional potential survivors and declarations regarding previous claims or lawsuits related to toxic substance exposure. Instructions for completing the form and privacy information are provided.

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Click ‘Get Form’ to open the ee 2 document in the editor.
Begin by filling out the Deceased Employee Information section. Clearly print the name, sex, social security number, date of birth, and date of death. If applicable, indicate whether an autopsy was performed.
Next, complete the Survivor Information section. Provide your name, sex, social security number, date of birth, address, relationship to the deceased employee, and telephone numbers.
In Item 14, identify any diagnosed conditions related to work exposure. Be specific and attach any necessary medical documentation.
Proceed to answer questions regarding any lawsuits or workers' compensation claims in the Awards and Other Information section. Ensure you provide copies of relevant documentation if applicable.
Finally, list any other potential survivors in Item 22 and ensure all information is accurate before signing and dating at the bottom of Page 2.

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Ee 2 2026

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