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This version of the form is not currently in use and is provided for reference only. Download this version of
Form EE-4
for the current year.
Form EE-4 Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act
What Is Form EE-4?
This is a legal form that was released by the U.S. Department of Labor - Office of Workers' Compensation Programs on November 1, 2016 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is the Form EE-4?
A: The Form EE-4 is an Employment History Affidavit.
Q: What is the purpose of the Form EE-4?
A: The purpose of the Form EE-4 is to support a claim under the Energy Employees Occupational IllnessCompensation Program Act.
Q: Who needs to complete the Form EE-4?
A: Employees who are filing a claim under the Energy Employees Occupational Illness Compensation Program Act need to complete the Form EE-4.
Q: What information is required on the Form EE-4?
A: The Form EE-4 requires information about the claimant's employment history, including details about their former employers, job duties, and exposure to certain hazards.
Form Details:
- Released on November 1, 2016;
- The latest available edition released by the U.S. Department of Labor - Office of Workers' Compensation Programs;
- Easy to use and ready to print;
- Yours to fill out and keep for your records;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form EE-4 by clicking the link below or browse more documents and templates provided by the U.S. Department of Labor - Office of Workers' Compensation Programs.
Download Form EE-4 Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Program Act
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