Fillable WAGE AND SALARY VERIFICATION (Geico Claims)

Fill Online, Printable, Fillable, Blank WAGE AND SALARY VERIFICATION (Geico Claims) Form

Use Fill to complete blank online GEICO CLAIMS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

WAGE AND SALARY VERIFICATION (Geico Claims)

On average this form takes 34 minutes to complete

The WAGE AND SALARY VERIFICATION (Geico Claims) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 137 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Geico Claims forms online.

BROWSE GEICO CLAIMS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
If you missed time from work because of injuries sustained in the accident and you intend to file a
claim for medical or wage loss expenses, you must have your employer complete the Wage and
Salary Verification form.
You will need to print this form, fill out the current date, your name, the date of the accident and
your claim number, and give the form to your employer. Your employer will need to complete the
form and return it to GEICO.
Instructions
(Form Below)
GOVERNMENT EMPLOYEES INSURANCE COMPANIES
WAGE AND SALARY VERIFICATION
DATE
OUR POLICYHOLDER
DATE OF ACCIDENT
CLAIM NUMBER
Employee’s Name
Employee’s Address
Dear Sir or Madam:
The above named person sustained injuries as a result of an automobile accident on the date indicated. We understand this person is
your employee or former employee. To determine what monies may be due to the injured party, please provide us with responses to
the following questions, and return this form promptly. Thank you for your cooperation.
GOVERNMENT EMPLOYEES INSURANCE COMPANIES
CLAIMS DEPARTMENT
3535 WEST PIPKIN ROAD
LAKELAND, FL 33811
1. Occupation: ______________________________________________
2. Date of Employment: From: _______________ Through: _______________
3. Dates absent following accident: From: _______________ Through: _______________
4. Was employee paid during this absence? Yes___ No___ If Yes, Amount Paid $_____________
5. Is employee entitled to benefits under a wage or salary continuation plan? Yes___ No___
6. Name of your Workers’ Compensation Insurer: ______________________________________________________________
7. Has or will a claim be filed under any Workers’ Compensation Law for this accident? Yes___ No___
WEEK
NO.
WEEK
NO. OF
DAYS
WORKED
AMOUNT
EARNED
INCLUDING
OVERTIME OR
EXTRA WORK
ADDITIONAL COMPENSATION
GROSS
EARNINGS
FROM
DATE
TO
DATE
MEALS BOARD TIPS ALL OTHER
1
2
3
4
5
6
7
8
9
10
11
12
13
TOTAL
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
EMPLOYER: __________________________ DATE: __________ PHONE #: __________________ TITLE: ________________
SIGNED: ______________________________________________ PRINT NAME_____________________________________
C-255FL (04-04) NS
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

WAGE AND SALARY VERIFICATION (Geico Claims)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 January 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document