Alliance System Federation

Brotherhood of Maintenance of Way Employees Division
Alliance System Federation

1085 West State St.
Alliance OH, 44601
(330) 680-4100

Time Limits start on the date of occurrence (violation). Submit this form as soon as possible to insure time limits are met. Information in this form will be used to develop a written claim or grievance. Please fill out the entire form to ensure accuracy and provide as much detail as possible.

TO: *

(Designated Carrier Officer to Receive Claim)

Date: *

WHO is claiming?

Claimant Name *

ID # *

Address *

City *

State *

Zip *

Phone (1) *

Phone (2)

Phone (3)

Headquarters *

Gang No. *

Position *

Work Hours

A.M.

A.M. to

P.M.

Choose one *

Seniority dates:

Position

Date

Position

Date

Position

Date

Present Position: *

Working

Furloughed

Adjustment Requested:

ST Hrs =

OT Hrs =

DT Hrs =

List any additional claimants:

Name

Employee No

Seniority Date

Position

Pay Rate

Name

Employee No

Seniority Date

Position

Pay Rate

Name

Employee No

Seniority Date

Position

Pay Rate

Name

Employee No

Seniority Date

Position

Pay Rate

Name

Employee No

Seniority Date

Position

Pay Rate

List any witnesses:

WHAT did the company specifically do that violated the Agreement? (Who, What, When, Where) *

WHAT rule(s) do you feel were violated? *

Who is being claimed? *

ID # *

Assigned Position

Seniority Date *

Headquarters

Regular Assigned Hours

WHEN did the violation occur? *

Date(s) of violation *

Time: (From) *

(To) *

Total hours involved *

Is this claim/violation continuing? *

WHERE did the violation occur? *

Location (M.P.) *

Station/Yard *

Seniority District *

Division *

Town *

State *

IF THIS IS A CONTRACTING OUT VIOLATION: *

Name of Contractor

Number of Contractor’s employees

Time worked each day

Date(s) worked

Type of equipment used:

Explain what the contractor was doing

I hereby authorize my Representative to make resolution of this claim

Confirmation *

By checking this box you understand that incomplete or inaccurate information can lead to your claim not being progressed.

Signature *

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

Lodge # *

Employee ID # *

Additional Information