Gig Worker Settlement Claim Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Which gig platform(s) did you work for during the settlement period?

Approximate dates you worked for the platform(s) (e.g., Jan 2022 - Dec 2023)

Describe your role(s) or job title(s) as a gig worker

Estimated total hours worked during the settlement period

Upload any supporting documentation (e.g., pay stubs, work records)

Preferred payment method for settlement

Other

Tax status (choose the option that best describes you)

Other

Signature (please sign below)