Subcontractor Worksheet
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Employee Name: |
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Occupation: |
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Claimed Employment Dates |
Claimed Covered Facility |
Claimed Subcontractor |
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Verified Contract/Employment |
Verified Earning |
Verified on Premises |
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Subcontractor Worksheet
(Example)
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Claim Number: |
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Employee Name: |
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Occupation: |
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123-45-6789 |
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A.B. Cees |
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Carpenter |
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Claimed Employment Dates |
Claimed Covered Facility |
Claimed Subcontractor |
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Verified Contract/Employment |
Verified Earning |
Verified on Premises |
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1982 |
Portsmouth GDP |
Terstep Company |
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Yes-DOE confirmed entire employment |
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clearance card |
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1983 |
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" |
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1984 |
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" |
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1985 |
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" |
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1986 |
Baker Brothers |
ACME Builders |
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SSA records |
EE-4 from Former co-worker, D.E. Fees |
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1987 |
" |
" |
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EE-4 from widow only |
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