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Wage Loss Verification Form Template

Easily Document Your Lost Wages with Our Form

Dealing with lost wages due to an injury can be overwhelming, but our Wage Loss Verification Form Template simplifies the process for you. This template is designed for injured workers and employers looking to accurately document wage losses related to accidents or illnesses. By using this form, you can ensure detailed records, streamline the claims process, and add clarity to your financial documentation, making it easier to secure support. Start using this handy template today to make your wage verification straightforward and hassle-free.

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Employee full name
Claim or reference number
Employee email
Date of injury or incident
Employer or company name
Employer email
Employment status
Full-time
Part-time
Temporary/Seasonal
Contractor
Prefer not to say
Other
Please Specify:
Job title
First day of employment
Is employment currently active?
Yes
No
Usual hours per week
Less than 20
20-29
30-34
35-39
40
More than 40
Varies
Pay basis or frequency
Hourly
Daily
Weekly
Biweekly
Semimonthly
Monthly
Per diem
Commission-based
Other
Please Specify:
Base pay rate (enter amount and unit, e.g., $25/hour)
Is an overtime rate applicable?
Yes
No
Average gross weekly earnings in the 13 weeks before injury
Does the employee receive tips or gratuities?
Yes
No
First date the employee was unable to work due to the injury
Last date the employee was unable to work (leave blank if ongoing)
Work status during this period
No work
Light duty with reduced hours
Light duty with full hours
Modified duties
Working from home
Not applicable
Other
Please Specify:
Total number of work hours missed
Was paid sick leave or PTO used for any missed time?
Yes
No
Total gross wages paid during the wage loss period
Estimated overtime hours lost during this period
Were wages paid for any portion of the missed time?
Yes
No
How are the amounts reported above stated?
Gross
Net
Not sure
Employer-paid benefits that continued during the absence
Health insurance
Retirement contributions
Paid time off accrual
Short-term disability
Long-term disability
None
Other
Please Specify:
Notes or context relevant to wage loss (e.g., scheduling, light duty, other factors)
Employee name (authorization)
Date of employee authorization
I consent to the release of my wage and employment information for claim purposes
Yes
No
Authorized representative full name
Title or position
Representative email
Date signed
I certify that the information provided is accurate to the best of my knowledge
True
False
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Paper art illustration depicting a wage loss verification form with various sections for information and signatures

When to use this form

Use this form when an employee lost income because they could not work due to an injury, car accident, or illness. It fits personal injury and auto claims, workers compensation cases, and short-term disability requests. HR and payroll can confirm dates missed, pay rates, overtime, tips, and any PTO or disability pay used. Insurers, attorneys, and claimants get a clear record to calculate actual lost earnings and resolve disputes faster. If you only need current pay details without time loss, use the Wage verification form. To share payroll data lawfully, attach a signed Employment verification release form. With these details, you can confirm eligibility, document the loss period, and speed up approvals.

Must Ask Wage Loss Verification Questions

  1. What are the employee's job title, employment status, and start/end dates?

    This baseline proves the person worked for the employer during the claimed period and sets eligibility. It also helps align records across HR and payroll, reducing back-and-forth.

  2. On which dates and how many hours did the employee miss work due to the incident, with any medical restrictions?

    Specific dates and hours anchor the loss window so you can compute days and hours owed. Referencing restrictions explains why work was not possible and prevents disputes about availability.

  3. What is the regular pay rate, pay frequency, and average weekly hours, including overtime, tips, and commissions?

    These details let you calculate the average weekly wage and avoid underpaying variable earners. If this request is part of a broader file review, coordinate data with the Application verification form.

  4. What paid benefits were used for the missed time (sick, PTO, disability), and at what pay percentage?

    This prevents double recovery by showing what was already paid and at what rate. It also clarifies any offsets the insurer or employer must apply.

  5. Has the employer offered light-duty or alternative work, or paid any partial wages during recovery?

    Documenting modified duty and partial pay shows mitigation efforts and real losses. It helps decision makers determine net wage loss for approval or settlement.

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