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