Printing - FECA-PT2 - National Association of Letter Carriers

2-0806 Exhibit 8: Sample Letter to Claimant--General
Dear CLAIMANT NAME:
I am writing in reference to your claim for benefits under the Federal Employees' Compensation Act
(FECA) for [CONDITION OR LOCATION OF ILLNESS]. We have received and reviewed [DESCRIBE WHAT
WAS RECEIVED]. This information is not sufficient for us to determine whether you are eligible for
benefits because [EXPLAIN WHY EVIDENCE INSUFFICIENT].
Please provide the information requested below to us at the address on the letterhead. Include as much
detail as possible. Send a copy of your response to your employer for comments.
1. Describe the work-related exposure or contact which you believe contributed to your condition:
a. To what were you exposed?
b. How were you exposed? What tasks did you perform which required the claimed exposure
or contact?
c. How often were you exposed? For how long on each occasion?
2. Describe all exposure outside your Federal employment, i.e. in other work, at home, or with any
hobbies, which is similar to the working conditions which you believe led to your illness.
3. Describe the development of the claimed condition. When did you first notice it? Has it come and
gone or has it been present continuously? What symptoms have you had? What seems to make the
condition worse? Better? What treatment has been effective in controlling or curing it?
4. Describe all previous similar conditions.
5. Provide a comprehensive medical report from your treating physician which describes your
symptoms; results of examinations and tests; diagnosis; the treatment provided; the effect of treatment;
and the doctor's opinion, with medical reasons, on the cause of your condition. Specifically, if your doctor
feels that exposure or incidents in your Federal employment contributed to your condition, an explanation
of how such exposure contributed should be provided.
6. Provide the name, address and phone number of your attending physician(s).
7. Sign and return a medical release form for each physician or medical facility who has treated you
for the claimed condition. Two forms are enclosed for this purpose. This will allow us to correspond
directly with your physician(s) if additional information or clarification is necessary.
8. [FREE FLOW IF DESIRED]
We may write directly to a physician or any other party who may be able to provide information which will
help us decide your eligibility for benefits. Our efforts are intended to assist you in collecting evidence.
Please understand that it is ultimately your responsibility, as the claimant, to provide or ensure the
FECA-PT2 Printed: 06/08/2010 251