Fillable WAGE AND SALARY VERIFICATION (Geico Claims)

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WAGE AND SALARY VERIFICATION (Geico Claims)

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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
14111 DANIELSON STREET
POWAY, CA 92064
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
APPEAR ON THIS FORM:
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR
PAYMENT OF A LOSS IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
EMPLOYER: __________________________ DATE: __________ PHONE #: __________________ TITLE: ________________
SIGNED: ______________________________________________ PRINT NAME_____________________________________
C-255AZ (04-04) NS
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WAGE AND SALARY VERIFICATION (Geico Claims)

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Completed 12 April 2022

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