BR&CF Application for Membership
 

Brotherhood's Relief and Compensation Fund

300 Sterling Parkway, Suite 105, Mechanicsburg, PA 17050


DAILY BENEFIT LEVEL MONTHLY DUES RATE
$250.00 $81.25
$220.00 $71.50
$200.00 $65.00
$180.00 $58.50
$150.00 $48.75
$120.00 $39.00
$100.00 $32.50
$80.00 $26.00
CONTINUOUS BENEFICIAL
MEMBERSHIP
DAYS OF
ELIGIBILITY
Less than 24 months 365
24 months but less than 48 365
48 months but less than 60 365
60 months or more 365
180 Maximum in All Instances Involving Waiver of Investigation Article XIII, Sec. 6

If your application is approved, your membership will be made effective the 1st day of the succeeding month, or upon successful completion of your new-hire probationary period, whichever occurs later. A dues payment is not required for new membership. New members receive their first two (2) months of membership at no cost.

The organization shall not be liable for benefits for any occurrence(s) wherein the cause(s) for the discipline assessed is related, in whole or in part, to any incident(s) that occur prior to the effective date of membership.

Personal Information
SSN *

Name   *
     
Address   *

Email   *
   
Cell Number
Home Number
Date of Birth   *

Gender   *
Benefit Level Selection
SelectionBenefit Level:Monthly Dues
$250.00$81.25
$220.00$71.50
$200.00$65.00
$180.00$58.50
$150.00$48.75
$120.00$39.00
$100.00$32.50
$80.00$26.00
Dues Payment Authorization
The BR&CF has transitioned to a single method of collecting dues and distributing benefits.

By submission of this application, I authorize BR&CF to debit my membership dues from this account. A monthly deduction missed for any reason will simply be made up by double deduction the following month. In addition, I understand the BR&CF will utilize this account to directly deposit dues refunds, referral fees, and benefit payments.
Debit Date:      
       
Employment Information
Occupation *

Employer *
select

Labor Organization(Union) *

Date of Hire   *

Are you on probation as a new hire employee?   *
If yes, date to be completed:
RadDatePicker
RadDatePicker
Membership cannot be considered if the new-hire completion date is over 60 days from now. Please reapply within 60 days of completion.
 
Discipline History
Have you had any recent occurrences or incidents for which potential discipline might still be pending?
      *

Have you had any occurrences or incidents at any time in your railroad career which resulted in dismissal?
      *

Have you had any occurrences or incidents within the past five (5) years which were handled under a Discipline Diversion Program or which resulted in any of the following: Actual Suspension, Deferred Suspension, Record Suspension, Time Served, Demerits, Probation, or Decertification/Revocation of FRA Certificate?
      *  

Are you currently serving probation due to discipline or due to an occurrence or incident handled under a Discipline Diversion Program?
      *  
Referring Member
Did anyone refer you to the BR&CF?   *
Member ID
Name
 
Beneficiary
A $50,000 accidental death and dismemberment policy while on duty only is provided at no additional cost to members "In Good and Regular Standing". Please provide us with the following information and update as necessary.
Name
     
Relationship