Claim for medical or wage loss expenses, you must have your employer complete the Wage and 2026

1. Click ‘Get Form’ to open it in the editor.
2. Fill in the current date, your name, the date of the accident, and your claim number at the top of the form.
3. Print the form and provide it to your employer for completion.
4. Your employer will need to fill out their responses regarding your occupation, employment dates, and any absences following the accident.
5. Ensure they indicate whether you were paid during your absence and if you are entitled to benefits under a wage continuation plan.
6. The employer should also complete the schedule of weekly earnings for the 13 weeks prior to the accident, detailing amounts earned including overtime.
7. Once completed, have your employer sign and date the form before returning it promptly to GEICO.

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