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Lost Wages Form for Medical Malpractice Case

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DATE ____________________


This wage and bonus loss form is for the benefit of your employee in his or her claim arising out of an instance of medical malpractice that in no way arose in connection with his or her employment with your company. It will be to your employee's advantage if this form is filled out completely.

Employer name: __________________________

Company address: __________________________

Name of employee: __________________________

Social security no. : __________________________

Telephone: __________________________

Date employed: __________________________

Time lost from work : from __________________ to _________________

Salary: $ ______________ per ______________

Hours worked per week: ___________________________________________

Bonus, commission or overtime lost, if any : $___________________

Employee’s regular duties:


Signed ________________________________

Official title ________________________

Telephone ___________________________

I hereby authorize my employers to release the requested wage and bonus information to my attorneys:


Employee signature: ______________________________________

Date: ______________________________________

Client Reviews
Jonathan Rosenfeld was professionally objective, timely, and knowledgeable. Also, his advice was extremely effective regarding my case. In addition, Jonathan was understanding and patient pertaining to any of my questions or concerns. I was very happy with the end result and I highly recommend Jonathan Rosenfeld. Michonne Proulx
Extremely impressed with this law firm. They took control of a bad motorcycle crash that left my uncle seriously injured. Without any guarantee of a financial recovery, they went out and hired accident investigators and engineers to help prove how the accident happened. I am grateful that they worked on a contingency fee basis as there was no way we could have paid for these services on our own. Ethan Armstrong
This lawyer really helped me get compensation for my motorcycle accident case. I know there is no way that I could have gotten anywhere near the amount that Mr. Rosenfeld was able to get to settle my case. Thank you. Daniel Kaim
Jonathan helped my family heal and get compensation after our child was suffered a life threatening injury at daycare. He was sympathetic and in constant contact with us letting us know all he knew every step of the way. We were so blessed to find Jonathan! Giulia
Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
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