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EN-11A Impairment Benefits Response Form

EN-11A Impairment Benefits Response Form 2026

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This document is a letter regarding a claim under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). It informs the recipient that their claim has been accepted and outlines their potential eligibility for monetary benefits based on impairment ratings related to accepted illnesses. The letter details the process for obtaining an impairment evaluation, including requirements for physicians, and provides instructions for responding to the claim. It also includes privacy and public burden statements related to the information collection.

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Click ‘Get Form’ to open the EN-11A Impairment Benefits Response Form in our platform.
Begin by entering your Case ID Number and personal details, including your name, street address, city, state, and ZIP code.
Indicate whether this is your first, second, or final request by checking the appropriate box.
In the section regarding impairment benefits, check 'YES' if you wish to pursue a claim. If you select 'NO', you can still file for benefits in the future.
Choose one of the two options for your impairment evaluation: either have DEEOIC arrange a qualified physician or select your own. Provide the necessary details if you choose your own physician.
Sign and date the form at the bottom to validate your submission before mailing it to the specified address or faxing it.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What can I do on an EDP portal?

The Energy Document Portal (EDP) is an electronic document submission system that allows Energy Employees Occupational Illness Compensation Program Act (EEOICPA) claimants to file a new claim, file a consequential claim, complete benefit payment forms, electronically submit documents to their existing case file, and/or

How do I get my impairment rating?

During an IRE, you will attend an in-person appointment with the physician conducting the exam. If you intentionally fail to attend the appointment, you risk losing your workers compensation benefits. The physician may conduct various physical exams and tests at the appointment and take scans such as X-rays.

How to calculate your impairment rating?

If your average weekly wage is $500, for example, and your impairment percentage is 12%, then the calculation would be (. 667 x $500) x 12% x 1 which comes out to around $40 per week, payable over a 425 week period. This would have a value of $17,000 paid out over the 425 week period.