Lost Income Verification Letter Template to Send to Employer

Get the proof of lost wages you need for your personal injury claim. Use this free and easy downloadable form to send to your employer.

When you’ve been injured by the negligence of a person or business, you’re entitled to pursue compensation for all your losses – including lost wages.

The at-fault party’s insurance company won’t tell you that you can ask to be reimbursed for time you had to miss work, even if you used vacation time or sick leave. After all, you burned your paid time off to recover from injuries, time you can’t get back for vacation or other personal uses.

We make it easy for you to ask your employer for lost income verification with a downloadable form letter that lets you fill in the blanks with your own information.

Click on the image below to download the PDF letter with fillable fields:

Lost income verification letter template

How to Use the Lost Income Verification Letter

Click on the letter image to download the fillable PDF. Type into the highlighted sections to fill in the blanks with your employer’s contact information and your information.

Print out the letter and sign your name on the line next to Employee’s Name. It’s best to sign with blue or black non-erasable ink.

Make a copy of the signed letter for your injury claim file. Send the original signed letter to your employer. You might get a faster response if you include a self-addressed stamped envelope.

When you get the completed form letter back from your employer, make a copy and retain the original in your claim file. Never give the insurance company the original of any document.

Getting Full Compensation for Lost Income

Next to the cost of medical care, lost wages are one of the largest parts of a typical injury claim settlement. It pays to make sure that your claim for lost wages is complete and fully supported.

You are entitled to seek compensation for time off work from your injury that caused you to “spend” your vacation time, personal leave, or sick leave.

If part of your income before the injury came from overtime, you can provide a series of pay stubs that show the overtime hours you usually worked. If you missed overtime because your injuries kept you out of work during your employer’s busy season, you’re still entitled to seek reimbursement for the lost opportunity to make more money.

Perks like gas or food allowances are part of your total work income, so missed perks count toward your injury claim compensation.

In addition to your employer’s signed statement of lost wages, be sure to provide the insurance company with copies of the work restrictions from your doctor, as well as medical records containing doctor’s notes that justify the medical necessity for you to miss work.