Wage Form PDF Details

In the realm of personal injury and insurance claims, timely and accurate wage verification plays a pivotal role, especially when it comes to "No-Fault" insurance benefits following an automobile accident. This critical process is initiated through a Wage and Salary Verification form, a document that meticulously seeks to gather essential employment and wage details of an individual who has suffered injuries in such incidents. By requiring employers to furnish detailed employment dates, absence periods post-accident, salary payments during absence, entitlement to salary continuation benefits, Workmen's Compensation insurance specifics, and, crucially, a comprehensive schedule of weekly earnings for the 13 weeks preceding the accident, this form serves as a cornerstone for determining the eligibility and extent of benefits the injured party may receive. Embedded within this procedural document are legal safeguards against fraud, underscored by references to Florida Statute Sections that sternly address the submission of false or misleading information. Additionally, it embodies an authorization section, empowering the employee to facilitate the necessary information exchange between their employer and the representing law or insurance entities, thereby streamlining the path towards rightful compensation.

QuestionAnswer
Form NameWage Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshow to get a wage inquiry, wage and salary verification form, wage inquiry georgia department of labor, wage document

Form Preview Example

WAGE AND SALARY VERIFICATION

Date

Our Policyholder

Date of Accident

File Number

 

 

 

Employee’s Name and Address

To Whom It May Concern:

The above named person has applied for benefits under the “No-Fault” Insurance as a result of injuries in an automobile accident on the date indicated. We understand this person is your employee or former employee. To determine if benefits that may be due the applicant, this law requires you to provide us with the answers to the following seven questions, and to return this form promptly. Thank you for your cooperation.

1.

Dates of Employment:

From:______________ Through:________________

2.

Dates absent following accident:

From:______________ Through:________________

3.

Was employee paid during absence?

Yes______ No______ If Yes, Amount paid?______

4.Is employee entitled to benefits under a wage or salary continuation plan? Yes_____ No_____

5.Name of your Workmen’s Compensation Insurer ____________________________________

6.Has or will a claim be filed under Workmen’s Compensation Law for this accident? Yes_______ No _________

7.SCHEDULE OF WEEKLY EARNINGS - For 13 Weeks Prior to Date of Accident

 

Wk. No

 

 

 

No of

Amount Earned

 

 

 

 

 

 

From

 

To

Days

Including Overtime or Extra Work

 

 

 

 

Gross Earning

 

 

 

 

 

 

Worked

 

_____

_____

_____

_____

 

 

Date

 

Date

 

 

Meals

Board

Tips

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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TOTAL

Employer___________________________ Date___________ Signed_________________ Title_______________

(Pursuant to Florida Statute Section 17.234, any person who knowingly and with intent to injure, defraud or deceive any insurance company by filing a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.)

Pursuant to Florida Statute Section 27.736(6), under penalty of perjury, I declare that I have rad the foregoing and that the information provided above is true to the best of my knowledge and belief.

AUTHORIZATION

I, the undersigned client hereby authorize my employer to give the above information to the Law Office of Singer, Farbman & Associates, my attorneys and/or my insurance carrier.

______________________________

EMPLOYEE/CLIENT

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2. The next step is usually to complete these blanks: Date, Meals, Board, Tips, Other, and Wk No From Date.

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3. This next segment is all about TOTAL, Employer Date Signed Title, Pursuant to Florida Statute, and AUTHORIZATION - complete each of these blank fields.

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4. Filling in I the undersigned client hereby, and EMPLOYEECLIENT is essential in this stage - be sure to be patient and be attentive with every single empty field!

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