Wage Loss Packet - Sam Lee


WAGE LOSS INSTRUCTIONS

One of the most important aspects of your personal injury claim will be your lost earnings if you are unable to work for any length of time due to your injuries.

We ask your cooperation in obtaining the two items required to process your wage loss payment(s). These documents are:

  1. Wage and Salary Verification; and
  2. Attending Physician’s Report

Doctors generally complete the Attending Physicians Report while you are in their office. Attached you will find the Wage and Salary Verification Form and Attending Physician’s Statement. It is our suggestion that you provide your employer with this form and have it completed and returned to us so we can fully document your wage loss claim. Of course, if there are any questions concerning this procedure, please feel free to contact me.

 

WAGE AND SALARY VERIFICATION

DATE:
CLAIMANT:
DATE OF ACCIDENT:
FILE #:

EMPLOYER'S NAME AND ADDRESS:

EMPLOYEE'S NAME AND ADDRESS:

Social Security No.#

The above named person has applied for benefits as a result of injuries sustained in the above referenced date of accident. We understand this person is your employee or former employee. To assist us in determining benefits that may be due to this person, please provide us with the answers to the following questions. Thank you for your cooperation.

1. Occupation:

2. Dates of Employment: From: ___________________ To: ___________________

3. Wage and Salary as of Date of Accident:
Per Hour __$_______
No. of Hours Worked:
No. of Days Worked:
Per Week __$_______
_______ Per Day
_______ Per Day
Per Month __$_______
_______ Per Week

Leave this empty:

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