Employee's Wage Loss Authorization

DATE

DATE OF ACCIDENT

TO THE EMPLOYER:

This statement is for the benefit of your employee in his/her claim arising out of an accident THAT IS IN NO WAY CONNECTED WITH HIS EMPLOYMENT AT YOUR COMPANY. It will be to the employee's advantage if this form is filled out completely.

NAME OF EMPLOYER

ADDRESS

NAME OF EMPLOYEE

ADDRESS

PHONE

FIRST DATE EMPLOYED

(Approximate Date)

TIME LOST FROM WORK FROMTO(INCLUSI...