Claim for Benefits under Energy Employees - US Department of Labor 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with the 'Deceased Employee Information' section. Fill in the name, sex, social security number, date of birth, and date of death clearly. If an autopsy was performed, indicate the medical facility.
3. Proceed to 'Survivor Information'. Enter your details including name, relationship to the deceased, and contact information. Ensure accuracy as this information is crucial for processing your claim.
4. In 'Diagnosed Condition(s)', check the relevant boxes and provide specific diagnoses related to work exposure. Attach any necessary medical documentation if required.
5. Complete the 'Awards and Other Information' section by answering questions regarding previous claims or lawsuits related to the condition. Provide supporting documents if applicable.
6. Identify any other potential survivors who may qualify for benefits by providing their names and relationships in the designated area.
7. Finally, review all entries for accuracy before signing the declaration at the end of the form. Submit your completed claim to the appropriate district office.

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