Subcontractor Worksheet

Claim Number:

 

Employee Name:

 

 

Occupation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claimed Employment Dates

Claimed Covered Facility

Claimed Subcontractor

 

Verified Contract/Employment

Verified Earning

Verified on Premises

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                    Subcontractor Worksheet
                                                (Example)
 

Claim Number:

 

Employee Name:

 

 

Occupation:

 

123-45-6789

 

A.B. Cees

 

 

Carpenter

 

 

 

 

 

 

 

 

Claimed Employment Dates

Claimed Covered Facility

Claimed Subcontractor

 

Verified Contract/Employment

Verified Earning

Verified on Premises

1982

Portsmouth GDP

Terstep Company

 

Yes-DOE confirmed entire employment

 

clearance card

1983

 

"

 

 

 

 

1984

 

"

 

 

 

 

1985

 

"

 

 

 

 

1986

Baker Brothers

ACME Builders

 

 

SSA records

EE-4 from Former co-worker, D.E. Fees

1987

"

"

 

 

 

EE-4 from widow only