First name:

Last Name:

Phone Number:

Employee Number:

What is your position and crew you are assigned to and what is your location?:

Name of employee(s) doing work:

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

Please provide a detailed explanation and description of the work you are claiming:

When: Provide EXACT dates and hours the above employees worked on each of the dates

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

Why: Why was this work being performed? (Example: Emergency, snowstorm, rehabilitation, derailment, pre-planned, regularly scheduled, gang project, overtime):

What Rule has been Violated? Provide a detailed explanation of the actual VIOLATION:

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: