Lost Wage Statement PDF – Free Template for Injury & Accident Claims
Prove missed work and lost income with a clear lost wage statement PDF for insurers, lawyers, or HR.
Published November 22, 2025
Insurance companies and opposing counsel often demand clear proof of lost wages. This free tool builds a clean, printable lost wage statement so you can document missed time in one go.
When to use this
- You’re filing a personal injury claim and need to show how much income you lost.
- Your lawyer or adjuster asked for a formal lost wage statement from you or your employer.
- You want a clean, printable summary to attach to a demand letter or settlement packet.
How to do it (fast)
- Go to /tools/lost-wage-statement-pdf.
- Fill in claimant and employer info plus the incident date.
- Select hourly vs. salary, enter pay details, and add dates missed.
- Review the estimated lost wages and click Generate PDF to download and sign.
Why this helps
- Gives adjusters, lawyers, and HR a concise statement instead of scattered notes.
- Shows how totals were calculated (hourly or salary) so reviewers can verify quickly.
- Produces a signature-ready PDF you can attach to letters, emails, or court filings.
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Not legal advice. Courts set their own rules. Keep your original records.