Lost Wages Form for Medical Malpractice Case

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FIRM LETTERHEAD
WAGE AND BONUS LOSS FORM

DATE ____________________


TO THE EMPLOYER:

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:

Comments:

Signed ________________________________

Official title ________________________

Telephone ___________________________

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

______________________________________

Employee signature: ______________________________________

Date: ______________________________________

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