Lost Time Wages/Earnings Claim Form (DOB ADDED)

Lost Time Wages/Earnings Claim Form

ONLY COMPLETE IF NOT PAID LOST TIME WAGES BY EMPLOYER; to include straight time, sick time, or vacation time.
Member Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security #
Member Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Company Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Completed

MonthDayYear
Date
The Company DID NOT pay me Lost Time Wages either in the form of vacation/sick/straight time hours for negotiations and/or attending activities on behalf of the Local Union
Answer the following questions about your involvement in union activities and the period for which you are claiming loss time wages/earnings.
Union Activity
Date(s) of Union Activity - FROM

MonthDayYear
The start date from which you are claiming compensation for lost wages.
Date(s) of Union Activity - TO

MonthDayYear
The end date from which you are claiming compensation for lost wages.
Hours Claimed
Wage Rate ($/hour)
Sign Here
Signature Date

MonthDayYear
Date
Should be Empty: