This information is vital to distribution of relief funds and should be completed and returned as soon as possible. As the president of your local union, please review this form carefully before submitting.

Required Field Invalid Field DENOTES A REQUIRED OR INVALID FIELD. CLICK EACH ICON FOR MORE INFORMATION.

LOCAL UNION INFORMATION

President's First Name President First Name Required

President's Last Name President Last Name Required

Phone Number President's Phone Number Required

Secondary Phone Number

Local Number Local Number Required

Unit Number Unit Number Required

Local Address Address Required

Local Address 2

Local City City Required

Local State/Province State/Province Required

Local Postal Code Postal Code Required

Total Number of Hourly Employees Total Hourly Employees Required

Total Number of Union Members Total Union Members Required

EMPLOYER INFORMATION

Employer Name Employer Name Required

Employer Phone Number Employer Phone Required

Employer Address Address Required

Employer Address 2

Employer City City Required

Employer State/Province State/Province Required

Employer Postal Code Postal Code Required

DAMAGE INFORMATION

Please read the following information carefully. When finished, enter the total number of members affected per each level of the scale.

TOTAL AND COMPLETE LOSS

Total loss of home and personal items including dislocation.

SIGNIFICANT LOSS

Major wind and/or water damage to home and significant damage to personal items.

MODERATE LOSS

Significant roof loss, minor home flooding including basements and attached garages or numerous trees down but most repairs requiring more labor than materials.

LITTLE OR NO LOSS

Minimal resident damage, trees down, damage to fencing or non-resident structures but with the home mostly intact.

REVIEW & SIGN

The above information is accurate to the best of my knowledge.

Signature (Enter Your First & Last Name) Signature Required

I Agree & Have Reviewed My Assessment