WAGE LOSS VERIFICATION

COMPANY NAME

ADDRESS

TELEPHONE NUMBER

NAME OF EMPLOYEE

EMPLOYEES TITLE

DATE OF ACCIDENT

DATE HIRED

USUAL NUMBER OF DAYS WORKED PER WEEK : ____________________________

USUAL NUMBER OF HOURS WORKED PER WEEK :
FULL DAYS LOST FROM WORK DUE TO ACCIDENT (Specify Dates) :

PARTIAL DAYS LOST FROM WORK (Specify Dates and Number of Hours) :

SALARY AT TIME OF THE ACCIDENT

SALARY LOSS DUE TO ACCIDENT

Do not indicate whether salary was continued or not since California Law denies
a negligent party credit for wage continuation or disability benefits.
COMMENTS :

DATED :
SIGNATURE

PRINT NAME

TITLE