Local 110 Dues Assistance

Fill out this form and be sure to attach and/or mail in a doctor's statement.

For members experiencing loss of work due to illness/injury/natural disaster etc... Members receiving workman's comp do not qualify for assistance.

Name Name * First Last
Phone Phone * - ### - ### ####
Union Number *
Email
If injured or ill, please describe the nature of the injury/illness including the location
Date of Injury Date of Injury * / MM / DD YYYY
Is this work related? *

Is this work related? Yes No
Are you receiving workman's comp? *

Are you receiving workman's comp? Yes No
Non-injury/illness related hardships. The following criteria will be considered for dues assistance. Please note, additional information may be requested.

A. Illness of a member of the applicant’s family, resulting in loss to the family of income or extraordinary medical bills not covered by a welfare fund or health insurance;
B. Impending loss of property, such as foreclosure of the mortgage on the member’s home or repossession of an automobile necessary for transportation to work;
C. Natural disaster, such as fire, earthquake or flood, resulting in a substantial loss of property to the member;
D. Other reasons justifying dues assistance grant as determined by the Executive Board.
Summarize the circumstances that led to your financial hardships below.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Doctor's Statement
Attach here or mail it to 4532 S. Lindbergh, St. Louis, MO 63127
Fax to 314.892.5363

Attach Files

Local 110 Dues Assistance

Local 110 Dues Assistance

Non-injury/illness related hardships. The following criteria will be considered for dues assistance. Please note, additional information may be requested.