Get Wage Loss Verification Form Claimant - I2 Investigations I2 ...

The Wage Loss Verification Form Claimant is an important document designed to verify income loss due to work-related injuries. This guide provides clear, step-by-step instructions to help users complete the form efficiently and accurately online.

Follow the steps to fill out the Wage Loss Verification Form online.

1. Click ‘Get Form’ button to access the form and open it in your preferred editing tool.
2. Begin by entering your full name in the field labeled 'Claimant Name'. Make sure to provide your legal name as it appears on official documents.
3. Input your Social Security Number in the 'Claimant SSN' field. This information is sensitive and should be handled with care.
4. In the 'Employer Information' section, fill out the name of your employer, employer address, city, state, zip code, phone number, and fax number as requested.
5. Next, complete the 'Employee Information' section by stating your position and title, followed by a description of your duties within the role.
6. Proceed to fill in the 'Salary Information' section. Here, enter your salary per hour, the number of hours you work per week, and your average take-home pay.
7. Provide the dates of your employment by filling out the start and end dates in the designated fields.
8. Record your date of last worked in the corresponding field.
9. Indicate whether you were offered alternative work of light duty by selecting 'Yes' or 'No'. If applicable, describe the duties of the alternative work in the space provided.
10. Read the insurance fraud notice carefully. After understanding its implications, sign and date the form, and provide your direct phone number.
11. Once you have completed all sections of the form, you can save changes to the document, download it, print a physical copy, or share it as needed.

Complete your Wage Loss Verification Form online today to ensure timely processing of your claim.