Burlington Northern System Federation

Claim Form With Pictures

First name:

Last Name:

Employee Number:

Phone Number:

Email Address:

Did you witness the violation?

What is assigned crew and position?

Rules Violation:

Date of Violation:

Please provide a detailed explanation and description of the work you are claiming (Witness Statement):

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

Where: Provide details on location where the work was done, such as mile post limits, line segment, subdivision:

What equipment was used? What was the make and model of equipment and who operated the equipment?:

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

WHO IS CLAIMING THIS WORK: Please list your name and/or the names of the BMWED

Name of Contractor Employees Worked:

Number of Contractor employees:

What specific work is the equipment doing?

*EXTRA DETAILS THAT ARE HELPFUL BUT NOT NEEDED*

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

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 rented this type of equipment:

Signature:

Use your mouse, finger, or touch device to write your signature.