Get LA Lost Wages/Earnings Claim Form

Lost Wages/Earnings lost per week X Lost Wage Total Wkly Wage Wks out work 3. Did you miss more than one week of work Yes No If yes your physician must complete the DISABILITY VERIFICATION Form. 4. LOST WAGES/EARNINGS CLAIM FORM THIS FORM IS TO BE COMPLETED BY THE VICTIM CVR NUMBER Victim Name Claimant Name Your claim investigator is Phone NOTE The CVR board does NOT guarantee full payment of your lost wages. LOST WAGES CAN ONLY BE CLAIMED BY THE VICTIM STEP 1. GATHER THE FOLLOWING DOCUMENTATION TO VERIFY LOST WAGES/EARNINGS Have your employer complete the VERIFICATION FORM. If you missed more than one week of work you must have your physician complete the attached DISABILITY VERIFICATION form and attach it to the claim form when complete. Otherwise only one week can be reimbursed* If you are self-employed you must copy your tax return from the year of the crime incident and any contract bids estimates or other documents which might help verify your earnings and attach them to this claim form* If you are not self-employed you must have your employer complete the attached EMPLOYMENT/WAGES VERIFICATION FORM. You must also include with your claim your last tax return and/or W-2 or 3-4 pay stubs. Proof of disability income. STEP 2. ANSWER THE FOLLOWING QUESTIONS ABOUT LOST WAGES/EARNINGS Dates absent from work due to crime-related injuries From // to // Total Weeks Absent How many days did you work a week How many hours did you work each day 2. Were the loss of wages/earnings partially covered in part/full by any of the following sources If yes Beginning Date Ending Date Amounts received per week/month Union coverage Disability insurance Workers Compensation Sick Pay Vacation Pay Unemployment Other specify Provide documentation of the beginning dates and ending dates if applicable of payments. Complete the following information for all insurance and/or benefits plans that might cover this loss Company Name Phone Policy Number Group Number Address Street City State Zip Code NOTE IF ANY TYPE OF COVERAGE IS AVAILABLE YOU MUST APPLY FOR THOSE BENEFITS BEFORE FILING WITH THE CVR PROGRAM. LOST WAGES/EARNINGS CLAIM FORM THIS FORM IS TO BE COMPLETED BY THE VICTIM CVR NUMBER Victim Name Claimant Name Your claim investigator is Phone NOTE The CVR board does NOT guarantee full payment of your lost wages. LOST WAGES CAN ONLY BE CLAIMED BY THE VICTIM STEP 1. GATHER THE FOLLOWING DOCUMENTATION TO VERIFY LOST WAGES/EARNINGS Have your employer complete the VERIFICATION FORM. LOST WAGES CAN ONLY BE CLAIMED BY THE VICTIM STEP 1. GATHER THE FOLLOWING DOCUMENTATION TO VERIFY LOST WAGES/EARNINGS Have your employer complete the VERIFICATION FORM. If you missed more than one week of work you must have your physician complete the attached DISABILITY VERIFICATION form and attach it to the claim form when complete. If you missed more than one week of work you must have your physician complete the attached DISABILITY VERIFICATION form and attach it to the claim form when complete. Otherwise only one week can be reimbursed* If you are self-employed you must copy your tax return from the year of the crime incident and any contract bids estimates or other documents which might help verify your earnings and attach them to this claim form* If you are not self-employed you must have your employer complete the attached EMPLOYMENT/WAGES VERIFICATION FORM. .