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September 22, 2018
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Online Contracting Claim Form

The success of your time claim depends upon the information you provide; it needs to be specific and exact!  SUBMIT THIS FORM WITHIN 15 DAYS AFTER THE FIRST DAY OF THE VIOLATION TO ENSURE TIME LIMITS ARE MET UNDER ALL AGREEMENTS.

Please fill out this witness statement form, save it to your device and attach it to this claim when you submit it.

First name:

Last Name:

Phone Number:

Employee Number:

Email Address:

Did you witness this work?:

Name of Contractor:

Number of Contractor employees:

Was equipment used: If yes, what was the make and model of the equipment?

What specific work is the equipment doing:

When: Provide EXACT dates the above contractors worked

Hours: Provide the EXACT hours the above contractors worked 

Where: Provide exact details on location where the work was done, such as mile post limits, section, depot, platform, etc.

What: List any MOW forces that worked alongside or assisted the contractor and it's employees

List any equipment owned by the Railroad which could have done this work and where that equipment was located:

List any local business(es) where the Railroad could have rentred this type of equipment:

Provide a detailed explanation of the actual work being done by the contractor and it's employees:

WHO IS CLAIMING THIS WORK: Please list your name and/or the names of the BMWED members who are the employees regularly assigned to the work in question or who would be the senior employees claiming this work. 

What are the regular assigned hours and work week of the above claimants on the dates of this claim:

Add any comments that you may have regarding this claim that you think may help us:

Enter the text shown in the image above.

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