Please indicate as much as you can about the work (the project(s)) for which you were improperly (or not at all) compensated, or for which your employer failed to properly contribute on your behalf to the Funds (i.e. General Contractor, address of jobsite(s), lot numbers, number of hours worked per day, etc.). Use reverse for additional information.

Is there a particular month (or months) on your Monthly Work Statement that is incorrect?

If applicable, indicate the number of hours for which you were improperly (or not at all) paid:

If applicable, indicate the total amount of wages you are due to you from the employer:

If applicable, indicate the last day you worked for the employer on the project for which you were either improperly (or not at all):

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Signing above indicates that the information you have provided on this form is accurate and truthful. You certify that you have either not been properly (or not at all) paid for work that you performed for the employer identified, or that the employer identified has failed to properly report or contribute to the Painters District Council No. 30 Benefits Office for hours you worked on the project(s) specified. If applicable, you also confirm that you have reported any and all steps the employer may have taken to correct the matter, including issuing you payment for part or all of the amounts owed to you. Additionally, you promise to immediately report to the LMIDF any steps the employer may take to correct the matter, including issuing you payment for part or all of the amounts owed to you, at any time after the date of this Claim. Finally, by signing above, you acknowledge and agree: that your eligibility for or entitlement to benefits from the LMIDF is within the sole discretion of the Trustees; that your failure to timely provide any requested documentation in support of your claim may result in a denial or reduction of benefits; and, that you must follow the claims and appeals procedures provided by the LMIDF and exhaust such remedies in order to preserve any legal claim for benefits; and that if, after having received benefits from the LMIDF, you are paid by the employer for any work or contributions claimed to and paid by the LMIDF, you will promptly reimburse the LMIDF for all such benefit payments.

BENEFITS PROTECTION CLAIM

Benefits Protection Claim

Member Info

Employer Info

Type of Request

Type of Job

Information Provided

Details

Signature

Review Information and