Employee Wage Verification Form printable pdf download

Employee Wage Verification Form

Employee’s name:________________________________________________________

Employer:_______________________________________________________________

Employer’s address:_______________________________________________________

Employer’s phone no.:_____________________________________________________

Date of accident:__________________________________________

Occupation:______________________________________________

Dates of employment: from_____________________ to _______________________

Wage or salary as of date of incident: $____________________

( ) per week

( ) per hour

( ) per day

( ) per month

Tips or other supplemental income: $___________________

( ) per week

( ) per hour

( ) per day

( ) per month

Usual number of days worked per week:____________________

Usual number of hours worked per week:___________________

Dates absent following incident

Date disability began:__________________ Date returned to work:_________________

Has employee been paid during absence?

Yes( )

No( )

Sick leave: $_______________

Annual leave: $______________

Other: $________________

Signed:_________________________________

Date:_____________________

Title___________________________________

Employee Wage Verification Form