A wage loss verification form is a document which benefits the employees when they meet with an accident and they are unable to continue work, but can still receive compensation. The accident may not necessarily be taking place at the work place while using this type of form.
Sample Wage Loss Verification Form:
Address: Street address ________________ City name _____________ State ____________
Postal code _______________
Home phone number: ____________ Work phone number: _____________
Employer name: _______________
Employer address: __________ Street address ____________ City name: ________
Zip code: ____________
Salary details of the employee:
Salary paid per hour: ___________
Total number of working hours per week: ________________
Incentives, bonus or overtime pay (if applicable): ___________
Was there any loss in payment due to the accident?
Total number of working hours lost: _______________________
Total amount of payment lost: ________________ (total number of hours multiplied by salary paid per hour)
Signature of the employee