LOSS OF EARNINGS FORM

Our Client:
Date of Accident/Loss:

1. Position held by our client:

CONSTANT OFTEN SOMETIMES OCCASIONALLY RARELY NEVER

HEAVY LIFTING
OVERHEAD
REACHING
BENDING OR
STOOPING
STANDING
SITTING

2. Date of Hire:

3. Rate of pay for regular time: $ per

4. Usual number of hours worked per week:

5. Usual number of days worked per week:

6. Rate of pay for overtime: $ per

7. Dates absent following accident:

8. Total time lost from work:

9. Total overtime lost:

10. Please indicate if our client either lost or was delayed in obtaining any promotion or position, and provide sufficient detail as to the
extent of the delay and the differential in wages (continue on reverse if required):

11. Did our client lose his or her job as a result of the accident? Yes No If so, state reasons for losing job (continue on reverse if
required):

Name of Employer:

Address of Employer:

Signature and Title of person completing this form:

Date: Phone Number: ( )

If for some reason this questionnaire does not correlate with the nature of our client's employment or method of our client's payment for his/her services,
please contact us immediately. Add comments, if any, on the reverse.