Wage Loss Verification Form

July 21, 2011

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:

Employee Details:

Name: ________________

Designation: _________________

Address: Street address ________________ City name _____________ State ____________

Postal code _______________

Home phone number: ____________   Work phone number: _____________

Employer details:

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?

a)   Yes

b)   No

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

Dated: __________

 

Download Wage Loss Verification Form in Word Format

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