Wage Loss Verification Form
Wage Loss Verification Form
To the Employer:
This statement is for the benefit of your employee in their claim arising out of an accident that is in no way connected with their employment at your company. It will be to the employee's advantage if this form is filled out completely so that his or her claim may be properly evaluated.
Name of Employer: __________________________
Address: __________________________________
Name of Employee: _________________________
Address: _________________________________
Phone: __________________________________
Date of Injury: _______________________________
Type of Injury: _______________________________
Time Absent From Work: From___________ To_________
Average Salary: ______ per ________
Number of hours worked per week: ________
Bonus, Commissions or Overtime Lost if any: _______________
Total Wages Lost: ____________________________________
Employees Regular Duties: ____________________________
Comments: _________________________________________
Signed:
________________________ _________________________
Employee Employer/Official Title
http://www.lombardilaw.com/library/helpful-personal-injury-claim-forms.cfm
For good advice see a lawyer and if you have questions about this blog, the law or your case write or call me directly. Steve Lombardi, sdlombardi@aol.com and 515-222-1110. I handle all types of personal injury cases including car accidents, truck accidents, motorcycle accidents, workers' compensation cases. We help truckers all across the country who come through Iowa and end up in an accident. If we need other lawyers from other states we hire them and it costs you no more than what you would pay us; in other words, we split the fee between us. So call 515-222-1110 or email us at sdlombardi@aol.com. 
Quick Contact
Lombardi Law Firm
1300 37th Street, Suite 6
West Des Moines, IA 50266
Phone: 515-222-1110
Toll Free: 800-383-0331
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