Client Portal | WLC - Wage Loss

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Reviewing Legal Agreement

Wage Loss Information Portal

First Name

Phone Number

Date of Accident

Last Name

Email Address

Employment Information

Name of Employer

Last Day of Work

Job Title

Date Returned to Work

What Were You Earning at The Time of Accident?

Did You Receive Any Disability, Unemployment or Workers Compensation Benefits While Out?

If Yes, How Much Did You Receive in Benefits?

Documentation

For us to create the most accurate wage loss report for you, we need to include documentation that shows what you were earning before your accident as well as any other income you may received. If available please upload the following documents:

1. Paystubs from before your accident and after you returned to work.

2. Any tax returns that show your annual income.

3. If you received any benefits, please upload statements that show how much you received.

4. Any doctor's notes that state you were/are unable to work due to your injuries from your accident.

Upload Any Supporting Documents

Upload File

Upload supported file (Max 15MB)

Additional Notes Regarding Wage Loss

If you have any questions, concerns, or issues uploading documents, please email your representative that sent you this link or give us a call at 215-712-1711. Thank you for your assistance!

Thank you for submitting!

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