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This document serves as an affidavit providing the employment history of a living or deceased employee for the Energy Employees Occupational Illness Compensation Program.

How to fill out employment history affidavit for

How to fill out Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act

1. Obtain the Employment History Affidavit form from the Energy Employees Occupational Illness Compensation Program Act website or relevant office.
2. Read the instructions carefully to understand the requirements for filling out the affidavit.
3. Fill in your personal information, including your full name, address, and contact information.
4. Provide details of your employment history, including the names of employers, job titles, and dates of employment.
5. If applicable, include information about any job tasks related to radiation exposure or hazardous materials.
6. Gather any supporting documentation that can verify your employment history, such as pay stubs, tax forms, or employment letters.
7. Sign and date the affidavit to certify that all provided information is accurate and truthful.
8. Submit the completed affidavit and any supporting documents to the appropriate office handling your claim.

Who needs Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act?

1. Individuals who worked for the Department of Energy and its contractors or subcontractors.
2. Workers who may have been exposed to harmful substances or radiation while employed in relevant positions.
3. Claimants seeking compensation for illness related to their employment under the Energy Employees Occupational Illness Compensation Program Act.

People Also Ask about

Who is eligible for EEOICPA?

The Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA or the Act), as Amended, established a compensation program for the civilian men and women who, over the past 50 years, have performed duties uniquely related to the nuclear weapons production and testing programs of the Department of

Who is eligible for the Radiation Exposure Compensation Act?

About EEOICPA: Covered illnesses include radiation‐induced cancer, chronic beryllium disease, beryllium sensitivity, chronic silicosis, or any illness due to exposure to toxic substances.

What is an employee affidavit?

An affidavit of employment is a sworn statement confirming that an individual was or is currently working for a specific employer. The document contains information on the employee, the employer, the length of employment, and the employee's position and duties.

What is the payout for the EEOICPA?

$25,000 when an employee accrued between 10 and 19 years of qualifying wage loss; or • $50,000 when an employee had 20 years or more of qualifying wage loss. Benefits under Part E of the EEOICPA also include payment of medical expenses for covered conditions and compensation for permanent impairment.

What is the Energy Employees Occupational Illness Compensation Program Act?

As the Division of Energy Employees Occupational Illness Compensation (DEEOIC), our mission, under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA), is to protect the interests of workers who were injured or became ill on the job, or their families, by making timely, appropriate, and

Who is eligible for the EEOICPA?

To be eligible, an employee must have cancer, chronic silicosis, beryllium sensitivity, or chronic beryllium disease and worked at a covered DOE facility, atomic weapons employer facility, or a beryllium vendor facility during a specified time period.

What conditions are covered by the EEOICPA?

Part E of the EEOICPA compensates DOE contractor and subcontractor employees, eligible survivors of such employees, and uranium miners, millers, and ore transporters as defined by RECA Section 5, for any occupational illnesses that are causally linked to toxic exposures in the DOE or mining work environment.

For pdfFiller’s FAQs

What is Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act?

The Employment History Affidavit is a legal document that provides a detailed account of an individual's employment history relevant to their claim under the Energy Employees Occupational Illness Compensation Program Act, which aims to provide benefits to workers who have developed illnesses due to exposure to harmful substances while working in the energy sector.

Who is required to file Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act?

Individuals who are claiming benefits under the Energy Employees Occupational Illness Compensation Program Act due to occupational illnesses or injuries caused by exposure to hazardous materials while working in the energy sector are required to file the Employment History Affidavit.

How to fill out Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act?

To fill out the Employment History Affidavit, claimants must provide accurate details regarding their employment history, including the names and addresses of employers, job titles, dates of employment, and any specific work locations where exposure to hazardous materials occurred. The affidavit should be signed under penalty of perjury.

What is the purpose of Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act?

The purpose of the Employment History Affidavit is to establish a clear and documented employment history that links the claimant's occupational exposure to harmful substances, thereby supporting their claim for compensation under the Energy Employees Occupational Illness Compensation Program Act.

What information must be reported on Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act?

The information required on the Employment History Affidavit includes the claimant's full name, Social Security number, employment details (company names, addresses, job titles, and dates of employment), specific locations of work, and any relevant details about the nature of exposure to hazardous substances.