You may qualify for benefits

Name *

Name

First Name

Last Name

Phone (Your number will be used only be to provide information on benefits) *

Phone (Your number will be used only be to provide information on benefits)

(###)

###

####

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

My health has been affected because of my work exposure

Yes

Are you one of the following: Nuclear Industry, Uranium Industry, or Coal Industry Worker

Yes

I am a former Dept of Energy employee or subcontracted worker

Yes

I have filed a claim with the Dept. of Labor

I have worked at one or more of the following approved facilities

A representative will contact you shortly to discuss whether you may qualify for benefits under the EEOICPA Federal Program. Thank you.