Keep a complete record of all lost wages. Obtain a statement from your company outlining the time you have lost, the rate of salary you are paid, the hours you work per week, your average weekly salary, and any losses suffered as a result of this accident. Where possible, also obtain other types of evidence such as ledger sheets, copies of time cards, canceled checks, check stubs, vouchers, pay slips, etc.

After you return to work, have your employer fill out and sign the following form dealing with wage losses.

Employer Wage authorization You are hereby requested and authorized to furnish to the Law Office of Kenneth Vercammen and Associates, PC, whose address is: 407 Main Street, Metuchen, N.J. 08840, the information requested below, concerning my loss of wages or earnings as a result of injuries received in an accident on __________________________.

__________________________________ Employee

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1. When did employment start? __________________

2. What is the nature of employee's work? ______________

3. What is the average number of working days per week? __________

4. How much time did employee lose from work following the accident date? ______________________ (Set out inclusive dates and/or total hours absent.) Total number of hours or days lost ___________

5. How much money (gross and net) did employee lose due to this absence? _____________ Did the employee lose any overtime he/she may usually have earned? _____________

6. What was employee's regular pay rate? Answer only one: (a) Hourly and hours worked per day; _____________ (b) Weekly gross and net pay; _____________ (c) Semi-monthly gross and net pay; _____________ or (d) Monthly gross and net pay. _____________

7. How much, if any, of employee's sick leave or vacation time was used due to this absence? _____________

8. If any wages or earnings were paid to employee for period during which he/she was out: (a) how much was paid? (total) ________________________ (b) for what period? _________________________________ (c) nature of payment _________________________________

9. Date stopped work _____________________ 20 _________

10. Date returned to work ______________________ 20 _________ 11. Where any other benefits lost, forfeited or used, such as vacation time, sick leave, seniority rights, etc. ___________________________

12. Was employee reimbursed by NJ State Temporary Disability benefits or private insurance for lost wages.

It would be most appreciated if you would respond on your own business stationery. Many thanks for your assistance in this regard.

Date of reply: _______________, 20 ______ ____________________________ Title Name of company ____________________________ COMPLETE AND RETURN WITHIN 20 DAYS