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Get Wage Loss Verification

Wage Loss Verification Form This form is to be filled out by your employer. TO THE EMPLOYER This statement is for the benefit of your employee in connection with the claim for damages resulting from an accident which was in no way connected with our client s employment at your company. It would be beneficial to our client if this form is filled out completely. Name of Employer Your Name Your Position/Title Address Telephone Employee Information Employee s Position Employee s Duties Per hour Salary of Employee Did Employee lose any earnings due to this accident Hours Per week f Bonus commissions or overtime pay lost if any YES NO Hours lost multiplied by the wage of employee Total Hours Lost From Work Total amount lost from work Comments Any Person Who Knowingly Files A Statement Of Claim Containing Any False Or Misleading Information Is Subject To Criminal And Civil Penalties. Signed by Today s Date Print Your Name Your Contact Telephone Return to Bonar Law Group - 1 Centerpointe Dr. It would be beneficial to our client if this form is filled out completely. Name of Employer Your Name Your Position/Title Address Telephone Employee Information Employee s Position Employee s Duties Per hour Salary of Employee Did Employee lose any earnings due to this accident Hours Per week f Bonus commissions or overtime pay lost if any YES NO Hours lost multiplied by the wage of employee Total Hours Lost From Work Total amount lost from work Comments Any Person Who Knowingly Files A Statement Of Claim Containing Any False Or Misleading Information Is Subject To Criminal And Civil Penalties. Signed by Today s Date Print Your Name Your Contact Telephone Return to Bonar Law Group - 1 Centerpointe Dr. .

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