International Association of Bridge, Structural

International Association of
Bridge, Structural, Ornamental and Reinforcing Iron Workers
109 SELIG DRIVE, S.W. • ATLANTA, GEORGIA 30336
PHONE (404) 505-0022 • FAX (404) 505-1107 • TOLL FREE (888) 645-6559
Affiliated with AFL-C1O
LOCAL #387
ROBERT A. DUFFIELD
EFFECTIVE October 1st, 2014
Business Manager I F.S.-T.
JOURNEYMAN IRON WORKERS
BASE WAGE
$25.04
HEALTH & WELFARE
PENSION CONTRIBUTION
FUNDING SURCHARGE
387 WELFARE
APPRENTICE FUND
IMPACT
TOTAL
$ 4.00
$ 3.53
$ 1.16
$ 1.00
$ 0.67
$ 0.18
$ 35.58
DEDUCTIONS
WORK ASSESSMENT $1.15/hour flat rate
all hoars worked
$
$
$
$
DISTRICT COUNCIL
INTL. ORGANIZING
BUILDING TRADES
IPAL
0.02
0.07
0.02
0.03
APPRENTICE IRON WORKER
WAGES AND BENEFITS ARE SET BY THE APPRENTICE COMMITTEE. APPRENTICE
WAGES ARE NOT AN EXACT PERCENTAGE OF NEGOTIATED HOURLY
JOURNEYMAN WAGE. THESE WAGES ARE SUBJECT TO CHANGE.
*38% OF APPRENTICE PENSION CONTRIBUTIONS ARE SEPARATED INTO A
FUNDING SURCHARGE ALLOCATION.
Contributions
Base Wage
H&W
Pension*
Appr. Fund
Impact
Deductions
Building Trades
Dist. Council
I.P.A.L.
Intl. Organizing
Work Assess.
2
3
1
13.78 15.03 15.78
4.00
1.76
0.67 0.67 0.67
0.18 0.18 0.18
0.02
0.02
0.03
0.07
0.63
0.02
0.02
0.03
0.07
0.69
0.02
0.02
0.03
0.07
0.72
4
16.28
4.00
1.76
0.67
0.18
0.02
0.02
0.03
0.07
0.75
5
17.53
4.00
1.76
0.67
0.18
0.02
0.02
0.03
0.07
0.81
6
18.28
4.00
1.76
0.67
0.18
0.02
0.02
0.03
0.07
0.84
7
18.78
4.00
3.46
0.67
0.18
0.02
0.02
0.03
0.07
0.86
Page 1 of4 10/01/2014
8
20.04
4.00
3.46
0.67
0.18
0.02
0.02
0.03
0.07
0.92
ORGANIZED IRON WORKER
LOCAL #387
Local 387 has adopted the following procedure to bring in to
membership; unrepresented ironworkers in an effort to recapture all
phases of our work through a comprehensive and fair procedure will
benefit all members by increasing market share and result in higher
compensation and benefits for those who belong to this association.
Newly organized ironworkers will first undergo a skill assessment.
Based on this assessment, organized ironworkers will be referred at the following
rates:
o First six months - $12.00 up to $18.00 per hour, Deduction: work assessment,
Intl. Org. Fund, Bldg. Trades, District Council, IPAL Fund.
o First six months - Contributions of IMPACT..
• All first six month ironworkers will be given the opportunity to
upgrade their skills in an order to increase their wage.
Contributions
Base Wage
Impact
Deductions
Building Trade
Dist. Council
I.P.A.L.
Intl. Organizing
Work Assess.
1
2
12.00 13.00
.18
.18
0.02
0.02
0.03
0.07
1.15
0.02
0.02
0.03
0.07
1.15
4
3
14.00 15.00
.18
.18
0.02
0.02
0.03
0.07
1.15
5
16.00
.18
0.02
0.02
0.03
0.07
1.15
6
17.00
.18
0.02
0.02
0.03
0.07
1.15
7
18.00
.18
0.02
0.02
0.03
0.07
1.15
SECTION 2
Foreman Ironworkers - $ 2.00 over Journeyman scale.
General Foreman Ironworkers - $ 3.00 over Journeyman scale.
Page 2 of4
10/01/2014
0.02
0.02
0.03
0.07
1.15
SECTION 3
APPRENTICE IRON WORKERS
A.
Wages expressed as percentages of Journeyman rates for Apprentices
indentured after January 1, 2012.
First six months - 55%
Deductions: Building Trades, District Council, IPAL,
Intl. Organizing and 55% Standard Work Assessment.
Contributions: Apprentice Fund and IMPACT
Second six months - 60%
Deductions: Building Trades, District Council, IPAL, Intl. Organizing and
60% Standard Work Assessment. Contributions: Apprentice Fund and
IMPACT
Third six months - 63%
Deductions: Building Trades, District Council, IPAL, Intl. Organizing and
63% Standard Work Assessment. Contributions: Apprentice Fund .IMPACT,
Pension and H&W
Fourth six months - 65%
Deductions: Building Trades, District Council, IPAL, Intl. Organizing and
65% Standard Work Assessment. Contributions: Apprentice Fund .IMPACT,
Pension and H&W
Fifth six months - 70%
Deductions: Building Trades, District Council, IPAL, Intl. Organizing and
70% Standard Work Assessment. Contributions: Apprentice Fund .IMPACT,
Pension and H&W
Sixth six months - 73%
Deductions: Building Trades, District Council, IPAL, Intl. Organizing and
73% Standard Work Assessment. Contributions: Apprentice Fund .IMPACT,
Pension and H&W
Seventh six months - 75%
Deductions: Building Trades, District Council, IPAL, Intl. Organizing and
75% Standard Work Assessment. Contributions: Apprentice Fund .IMPACT,
Pension and H&W
Eighth six months - 80%
Deductions: Building Trades, District Council, IPAL, Intl. Organizing and
80% Standard Work Assessment. Contributions: Apprentice Fund .IMPACT,
Pension and H&W
Page 3 of4
10/01/2014
SECTION 4
Group E Non Upgraded Journeyman
LOCAL #387
Effective August 1st, 2013 all Journeyman must have successfully
completed the following listed upgrades:
OSHA 30
SUBPART R
Current Forklift, Current Snorkel lift, Current Scissor lift certifications
Current Scaffold Erector / Dismantle certification
Current First Aid CPR certification
International Iron Workers Rigging and Flagging certification
Current IMPACT Drug Test
Failure to comply with adopted mandates will result in all GROUP E Non
Upgraded Journeyman referred out at 80% of Journeyman wage.
*Work Assessments will be deducted from all wages. This will be deducted and paid by
each member (all classifications of workers) in accordance with Local #387 ByLa ws Art. 2 Section 1. Paragraph (c). Apprentice Work Assessment will be set by
the Apprentice Committee.
**Health & Welfare contribution to be paid at current rate. Apprentice wages are set by the
Apprentice Committee and are not an exact percentage of negotiated hourly
Journeyman wage. These rates are controlled by the Apprentice Committee and are
subject to change with minimal notice.
***Pension Contribution will be at $1.76 per hour from 3rd period apprentice through 6th period
apprentices while pension contribution for 7th and 8th period apprentices is $3.46 and Journeyman
Ironworkers at defined rate of per hour. *38% of Apprentice Pension Contributions are separated
into a Funding Surcharge allocation.
B.
C.
Deductions from Apprentice wages for the Work Assessment will be set by the
Apprentice Committee for all six month periods and will be a percentage of the
Standard Work Assessment.
In accordance with the terms of an individual signed authorization from the
Employee, deductions from gross wages of Employees may be made by the
Employer and remitted to the Union Trusts as follows:
1.
2.
3.
4.
5.
D.
Work Assessment Check-Off
District Council
Intl. Organizing
Building Trades.
IPAL
Reporting, collection and administration of Fringe Benefits and Work Assessments
Check-Off shall be mandated in Article 16, 17, 18, 19, 20 and 21 of the Agreement.
Page 4 of 4
10/01/2014
Code No.
JOURNEYMAN IRONWORKER
ATLANTA IRON WORKERS PENSION FUND LOCAL 387
Contractor_
ATLANTA IRON WORKERS JOINT APPRENTICEHIP COMMITTEE
IRON WORKERS LOCAL 387 WELFARE FUND
Ident. Number
JURISDICTION OF IRON WORKERS LOCAL UNION No. 387
Address
FOR OFFICIAL USE ONLY
Zip Code_
Telephone No._
NOTE: Contributions should reach us by the 10th of the month
following the month covered by this report
REPORT FOR PAYROLL MONTH OF
D PLEASE CHECK BOX IF THIS IS A NEW ADDRESS
EMPLOYEE NAME (Type or Print)
LAST
Over
TOTAL
WORK
D. C.
I.P.A.L.
BUILDING
INTERNATIONAL
LAST
SOCIAL
SECURITY
Straight
FIRST
Time
Time
CLOCK
ASSESSMENTS
ASSESSMENTS
ASSESSMENTS
TRADES
INITIAL
INITIAL
NUMBER
Hours
Hours
HOURS
$1.15 PER HOUR
.02 PER HOUR
.03 PER HOUR
.02 PER HOUR
ORGANIZING
.07 PER HOUR
CORRECT SOCIAL SECURITY NUMBER MUST BE SHOWN 1
CONTRIBUTION SCHEDULE - Effective the first full Payroll Period After 01 October 2014
Remit two copies to:
Pension
4.69/HR
Apprentice
0.67/HR
Impact Fund
0.18/HR
387 Welfare
1.00/HR
Atlanta Iron Workers Fringe Benefit Trust Fund
205 West 4th Street, Suite 225
Cincinnati, OH 45202
D Check Box to be sent more Benefit Forms -
Number Needed
D Please check here if you employed no men during this payroll period
and submit this form.
D Final Report.
CAUTION, READ BEFORE SIGNING:
TOTAL (1)
This undersigned employer, by signing this form, acknowledges, the above is true and correct and that he or it is bound to all terms
WORK ASSESSMENT TOTAL (2)
1.15/HR
and provisions of the current Collective Bargaining Agreement in existence as negotiated by Association of Steel Erectors and
Total D. C. Assessments
0.02/HR
Local Union No. 387 and further acknowledges that at all times and on all jobs, the same Union is the sole, exclusive bargaining
Total I.P.A.L. Assessments
0.03/HR
agent for all employees working in the craft jurisdiction of the Union as specified in the current Collective Bargaining Agreement.
Total Building Trades
0.02/hr
Total Int. Organizing
0.07/HR
Heavy Equipment Operators, Inc., and International Association of Bridge, Structural, Ornamental and Reinforcing Iron Workers
TOTAL (3)
TOTAL FUNDS REMITTED (1+2+3)
Authorized Signature
Code No.
PROBATIONARY IRONWORKER
ATLANTA IRON WORKERS PENSION FUND LOCAL 387
Contractor
ATLANTA IRON WORKERS JOINT APPRENTICEHIP COMMITTEE
IRON WORKERS LOCAL 387 WELFARE FUND
Ident. Number_
JURISDICTION OF IRON WORKERS LOCAL UNION No. 387
Address
Telephone No._
FOR OFFICIAL USE ONLY
Zip Code_
NOTE: Contributions should reach us by the 10th of the month
REPORT FOR PAYROLL MONTH OF
following the month covered by this report
D PLEASE CHECK BOX IF THIS IS A NEW ADDRESS
EMPLOYEE NAME (Type or Print)
SOCIAL
LAST
Straight
Over
TOTAL
WORK
D. C.
I.P.A.L.
BUILDING
FIRST
LAST
SECURITY
Time
Time
CLOCK
ASSESSMENTS
ASSESSMENTS
ASSESSMENTS
TRADES
ORGANIZING
INITIAL
INITIAL
NUMBER
Hours
Hours
HOURS
$1.15 PER HOUR
.02 PER HOUR
.03 PER HOUR
.02 PER HOUR
.07 PER HOUR
CORRECT SOCIAL SECURITY NUMBER MUST BE SHOWN
I
CONTRIBUTION SCHEDULE - Effective the first full Payroll Period After 01 October
Remit two copies to:
INTERNATIONAL
2014
Atlanta Iron Workers Fringe Benefit Trust Fund
205 West 4th Street, Suite 225
Pension
0.00/HR
Impact Fund
0.18/HR
387 Welfare
0.00/HR
Cincinnati, OH 45202
D
Check Box to be sent more Benefit Forms -
$
D
Please check here if you employed no men during this payroll period
D
Final Report.
Number Needed
and submit this form.
CAUTION, READ BEFORE SIGNING:
TOTAL (1)
This undersigned employer, by signing this form, acknowledges, the above is true and correct and that he or it is bound to all terms
and provisions of the current Collective Bargaining Agreement in existence as negotiated by Association of Steel Erectors and
WORK ASSESSMENT TOTAL (2)
1.15/HR
Total D. C. Assessments
0.02/HR
Local Union No. 387 and further acknowledges that at all times and on all jobs, the same Union is the sole, exclusive bargaining
Total I.P.A.L Assessments
0.03/HR
agent for all employees working in the craft jurisdiction of the Union as specified in the current Collective Bargaining Agreement.
Heavy Equipment Operators, Inc., and International Association of Bridge, Structural, Ornamental and Reinforcing Iron Workers
Total Building Trades
0.02/hr
Total Int. Organizing
0.07/HR
TOTAL (3)
TOTAL FUNDS REMITTED (1+2+3)
Authorized Signature
1ST & 2ND PERIOD
APPRENTICE IRONWORKER
Code No.
ATLANTA IRON WORKERS PENSION FUND LOCAL 387
Contractor
ATLANTA IRON WORKERS JOINT APPRENTICEHIP COMMITTEE
Ident. Number
IRON WORKERS LOCAL 387 WELFARE FUND
JURISDICTION OF IRON WORKERS LOCAL UNION No. 387
Address
Telephone No._
FOR OFFICIAL USE ONLY
Zip Code_
REPORT FOR PAYROLL MONTH OF
D PLEASE CHECK BOX IF THIS IS A NEW ADDRESS
EMPLOYEE NAME (Type or Print)
LAST
NOTE: Contributions should reach us by the 10th of the month
following the month covered by this report
SOCIAL
Straight
Over
TOTAL
FIRST
LAST
SECURITY
Time
Time
CLOCK
INITIAL
INITIAL
NUMBER
Hours
Hours
HOURS
WORK ASSESSMENTS
PER CBA
AGREEMENT
D. C.
I.P.A.L.
BUILDING
INTERNATIONAL
ASSESSMENTS
ASSESSMENTS
TRADES
.02 PER HOUR
.03 PER HOUR
.02 PER HOUR
ORGANIZING
.07 PER HOUR
CORRECT SOCIAL SECURITY NUMBER MUST BE SHOWN 1
CONTRIBUTION SCHEDULE - Effective the first full Payroll Period After 01 October 2014
Remit two copies to:
Pension
0.00/HR
Apprentice
0.67/HR
Impact Fund
0.18/HR
387 Welfare
.00/HR
Atlanta Iron Workers Fringe Benefit Trust Fund
205 West 4th Street, Suite 225
Cincinnati, OH 45202
S
Q Check Box to be sent more Benefit Forms -
Number Needed
D Please check here if you employed no men during this payroll period
and submit this form.
D Final Report.
CAUTION, READ BEFORE SIGNING:
TOTAL (1)
1ST PERIOD ASSESMENT
0.63/HR
This undersigned employer, by signing this form, acknowledges, the above is true and correct and that he or it is bound to all terms
2ND PERIOD ASSESMENT
0.69/HR
and provisions of the current Collective Bargaining Agreement in existence as negotiated by Association of Steel Erectors and
Heavy Equipment Operators, Inc., and International Association of Bridge, Structural, Ornamental and Reinforcing Iron Workers
WORK ASSESSMENT TOTAL (2)
Local Union No. 387 and further acknowledges that at all times and on all jobs, the same Union is the sole, exclusive bargaining
Total D. C. Assessments
0.02/HR
Total I.P.A.L. Assessments
0.03/HR
Total Building Trades
0.02/hr
Total Int. Organizing
0.07/HR
agent for all employees working in the craft jurisdiction of the Union as specified in the current Collective Bargaining Agreement.
TOTAL (3)
TOTAL FUNDS REMITTED (1+2*3)
Authorized Signature
Code No._
3RD &4TH PERIOD
APPRENTICE IRONWORKER
Contractor_
ATLANTA IRON WORKERS PENSION FUND LOCAL 387
Ident. Number_
ATLANTA IRON WORKERS JOINT APPRENTICEHIP COMMITTEE
IRON WORKERS LOCAL 387 WELFARE FUND
Address_
JURISDICTION OF IRON WORKERS LOCAL UNION No. 387
Telephone No._
FOR OFFICIAL USE ONLY
Zip Code_
NOTE: Contributions should reach us by the 10th of the month
following the month covered by this report
REPORT FOR PAYROLL MONTH OF
D PLEASE CHECK BOX IF THIS IS A NEW ADDRESS
EMPLOYEE NAME (Type or Print)
FIRST
INITIAL
LAST
LAST
INITIAL
SOCIAL
SECURITY
NUMBER
Straight
Time
Hours
Over
Time
Hours
TOTAL
CLOCK
HOURS
WORK ASSESSMENTS
PER CBA
AGREEMENT
I.P.A.L
ASSESSMENTS
D.C.
ASSESSMENTS
.02 PER HOUR
.03 PER HOUR
BUILDING
TRADES
.02 PER HOUR
INTERNATIONAL
ORGANIZING
.07 PER HOUR
CORRECT SOCIAL SECURITY NUMBER MUST BE SHOWN 1
CONTRIBUTION SCHEDULE - Effective the first full Payroll Period After 01 October 2014
Remit two copies to:
Atlanta Iron Workers Fringe Benefit Trust Fund
205 West 4th Street, Suite 225
Cincinnati, OH 45202
D Check Box to be sent more Benefit Forms -
Pension (3RD & 4TH PERIOD)
1.76/HR
Apprentice
0.67/HR
Impact Fund
0.18/HR
387 Welfare
.00/HR
Number Needed
D Please check here if you employed no men during this payroll period
and submit this form.
D Final Report.
CAUTION, READ BEFORE SIGNING:
TOTAL (1)
3RD PERIOD ASSESSMENT
.72/HR
This undersigned employer, by signing this form, acknowledges, the above is true and correct and that he or it is bound to all terms
4TH PERIOD ASSESSMENT
.75/HR
and provisions of the current Collective Bargaining Agreement in existence as negotiated by Association of Steel Erectors and
Heavy Equipment Operators, Inc., and International Association of Bridge, Structural, Ornamental and Reinforcing Iron Workers
WORK ASSESSMENT TOTAL (2)
Total D. C. Assessments
0.02/HR
Local Union No. 387 and further acknowledges that at all times and on all jobs, the same Union is the sole, exclusive bargaining
Total I.P.A.L. Assessments
0.03/HR
agent for all employees working in the craft jurisdiction of the Union as specified in the current Collective Bargaining Agreement.
Total Building Trades
0.02/hr
Total Int. Organizing
0.07/HR
TOTAL (3)
TOTAL FUNDS REMITTED (1+2+3)
Authorized Signature
5TH & 6TH PERIOD
APPRENTICE IRONWORKER
Code No.
Contractor
ATLANTA IRON WORKERS PENSION FUND LOCAL 387
ATLANTA IRON WORKERS JOINT APPRENTICEHIP COMMITTEE
Ident. Number
IRON WORKERS LOCAL 387 WELFARE FUND
Address
JURISDICTION OF IRON WORKERS LOCAL UNION No. 387
Telephone No._
FOR OFFICIAL USE ONLY
Zip Code_
NOTE: Contributions should reach us by the 10th of the month
following the month covered by this report
REPORT FOR PAYROLL MONTH OF
D PLEASE CHECK BOX IF THIS IS A NEW ADDRESS
EMPLdYEE NAME (Type or Print)
FIRST
INITIAL
LAST
SOCIAL
SECURITY
NUMBER
LAST
INITIAL
Straight
Time
Hours
Over
Time
Hours
TOTAL
CLOCK
HOURS
WORK ASSESSMENTS
PER CBA
AGREEMENT
D.C.
ASSESSMENTS
.02 PER HOUR
I.P.A.L.
ASSESSMENTS
.03 PER HOUR
BUILDING
TRADES
.02 PER HOUR
INTERNATIONAL
ORGANIZING
.07 PER HOUR
CORRECT SOCIAL SECURITY NUMBER MUST BE SHOWN ^^HJ-JEE
CONTRIBUTION SCHEDULE - Effective the first full Payroll Period After 01 October 2014
Remit two copies to:
Atlanta Iron Workers Fringe Benefit Trust Fund
205 West 4th Street, Suite 225
Cincinnati, OH 45202
D Check Box to be sent more Benefit Forms -
Pension
1.76/HR
Apprentice
0.67/HR
Impact Fund
0.18/HR
387 Welfare
. 00/HR
$
Number Needed
D Please check here if you employed no men during this payroll period
and submit this form.
D Final Report.
CAUTION, READ BEFORE SIGNING:
TOTAL (1)
5TH PERIOD ASSESSMENT
.81/HR
This undersigned employer, by signing this form, acknowledges, the above is true and correct and that he or it is bound to all terms
6TH PERIOD ASSESSMENT
.84/HR
and provisions of the current Collective Bargaining Agreement in existence as negotiated by Association of Steel Erectors and
Heavy Equipment Operators, Inc., and International Association of Bridge, Structural, Ornamental and Reinforcing Iron Workers
Local Union No. 387 and further acknowledges that at all times and on all jobs, the same Union is the sole, exclusive bargaining
WORK ASSESSMENT TOTAL (2)
Total D. C. Assessments
0.02/HR
Total I.P.A.L. Assessments
0.03/HR
Total Building Trades
0.02/hr
Total Int. Organizing
0.07/HR
agent for all employees working in the craft jurisdiction of the Union as specified in the current Collective Bargaining Agreement.
TOTAL (3)
Authorized Signature
TOTAL FUNDS REMITTED (1+2+3)
Code No.
7TH & 8TH PERIOD
APPRENTICE IRONWORKER
Contractor
ATLANTA IRON WORKERS PENSION FUND LOCAL 387
ATLANTA IRON WORKERS JOINT APPRENTICED COMMITTEE
Ident. Number_
IRON WORKERS LOCAL 387 WELFARE FUND
Address
JURISDICTION OF IRON WORKERS LOCAL UNION No. 387
FOR OFFICIAL USE ONLY
Zip Code_
Telephone No._
NOTE: Contributions should reach us by the 10th of the month
following the month covered by this report
REPORT FOR PAYROLL MONTH OF
D PLEASE CHECK BOX IF THIS IS A NEW ADDRESS
EMPLOYEE NAME (Type or Print)
FIRST
INITIAL
LAST
LAST
INITIAL
SOCIAL
SECURITY
NUMBER
Straight
Time
Hours
Over
Time
Hours
TOTAL
CLOCK
HOURS
WORK ASSESSMENTS
PER CBA
AGREEMENT
D. C.
ASSESSMENTS
.02 PER HOUR
I.P.A.L.
ASSESSMENTS
.03 PER HOUR
BUILDING
TRADES
.02 PER HOUR
INTERNATIONAL
ORGANIZING
.07 PER HOUR
CORRECT SOCIAL SECURITY NUMBER MUST BE SHOWN ^^flSE
CONTRIBUTION SCHEDULE - Effective the first full Payroll Period After 01 October 2014
Remit two copies to:
Pension
Atlanta Iron Workers Fringe Benefit Trust Fund
205 West 4th Street, Suite 225
Cincinnati, OH 45202
D Check Box to be sent more Benefit Forms -
3.46/HR
Apprentice
0.67/HR
Impact Fund
0.18/HR
387 Welfare
. 00/HR
Number Needed
D Please check here if you employed no men during this payroll period
and submit this form.
D Final Report.
CAUTION, READ BEFORE SIGNING:
TOTAL (1)
7TH PERIOD ASSESSMENT
.86/HR
This undersigned employer, by signing this form, acknowledges, the above is true and correct and that he or it is bound to all terms
8TH PERIOD ASSESSMENT
.92/HR
and provisions of the current Collective Bargaining Agreement in existence as negotiated by Association of Steel Erectors and
Heavy Equipment Operators, Inc., and International Association of Bridge, Structural, Ornamental and Reinforcing Iron Workers
Local Union No. 387 and further acknowledges that at all times and on all jobs, the same Union is the sole, exclusive bargaining
WORK ASSESSMENT TOTAL (2)
Total D. C. Assessments
0.02/HR
Total I.P.A.L Assessments
0.03/HR
Total Building Trades
0.02/hr
Total Int. Organizing
0.07/HR
agent for all employees working in the craft jurisdiction of the Union as specified in the current Collective Bargaining Agreement.
TOTAL (3)
Authorized Signature
TOTAL FUNDS REMITTED (1+2+3)
SOUTHEASTERN IRON WORKERS
HEALTH CARE PLAN
SEIW
(Date Received for Fund use only)
387
IW
GEMGroup, Fund Administrator
3 Gateway Center
401 Liberty Avenue STE 1200
Pittsburgh, PA 15222
1-800-242-8923
Report for
Ironworkers Local 387
Atlanta, Georgia
________ to _______
Document # ___________________
Participant Name
Social Security Number
Total Hours Worked
RATE per Hour Worked
FUND
Effective Date: 03-01-2013
X
Total Hours Worked:
Health Fund
$4.00
X
$4.00
= $
Total Document Amount
•
•
$
Report and payment are due in the Fund Office by the last day of the month following the work month.
Liquidated Damages will be assessed as outlined in the Collective Bargaining Agreement.
Employer Name________________________________________________
Address ______________________________________________________
______________________________________________________
______________________________________________________
Fed. I.D. No. ______________________
Phone No. ________________________
Fax No. __________________________
We certify this report to be true and correct and hereby accept and agree to abide by the terms and provisions as set forth in the Agreements and Declarations of Trust.
Check # __________________
Please check if: □ No Longer Working in Area
□ No Employees This Month
___________________________________________________
Authorized Signature
Date
Check here for more forms □
Check here if new address □
Make Check Payable to: Southeastern Iron Workers Health Care Plan, and mail White and Yellow copy of Report along with check to
GEMGroup at the address listed above.