AUTHORIZATION FOR RELEASE OF EMPLOYMENT RECORDS

Lost Wages and Employment Documentation

SECTION 1: EMPLOYEE INFORMATION

Employee Name: [________________________________]

Date of Birth: [________________________________]

Social Security Number: [________________________________]

Current Address:
Street: [________________________________]
City, State, Zip: [________________________________]

Phone Number: [________________________________]

Email Address: [________________________________]

SECTION 2: EMPLOYER INFORMATION

Current/Former Employer:
Company Name: [________________________________]
Address: [________________________________]
City, State, Zip: [________________________________]
Phone: [________________________________]
Fax: [________________________________]

Human Resources Contact: [________________________________]

Payroll Department Contact: [________________________________]

Employee ID Number: [________________________________]

Employment Dates:
Start Date: [________________________________]
End Date (if applicable): [________________________________]

Job Title/Position: [________________________________]

Supervisor Name: [________________________________]

SECTION 3: ADDITIONAL EMPLOYERS (if applicable)

Employer 2:
Company Name: [________________________________]
Address: [________________________________]
Employment Dates: [________] to [________]
Job Title: [________________________________]

Employer 3:
Company Name: [________________________________]
Address: [________________________________]
Employment Dates: [________] to [________]
Job Title: [________________________________]

SECTION 4: AUTHORIZATION TO RELEASE RECORDS

I, [EMPLOYEE NAME], hereby authorize the employer(s) identified above to release the following employment records and information to:

Authorized Recipient:
Attorney/Firm Name: [________________________________]
Address: [________________________________]
City, State, Zip: [________________________________]
Phone: [________________________________]
Fax: [________________________________]
Email: [________________________________]

SECTION 5: RECORDS TO BE RELEASED

Time Period Covered:

☐ From [DATE - typically 2 years before incident] to present
☐ From [START DATE] to [END DATE]
☐ Complete employment history with this employer

Employment Records Requested:

Personnel Records:
☐ Employment application and resume
☐ Offer letter and employment agreement
☐ Job description(s)
☐ Performance evaluations/reviews
☐ Disciplinary records
☐ Attendance records
☐ Personnel file (complete)
☐ Employment verification letter

Compensation Records:
☐ Pay stubs/earnings statements (all for period requested)
☐ W-2 forms (all years available)
☐ Salary history
☐ Wage rate history
☐ Overtime records
☐ Commission records
☐ Bonus records
☐ Incentive/profit sharing records

Time and Attendance:
☐ Time sheets/time cards
☐ Attendance records
☐ Sick leave usage
☐ Vacation/PTO usage
☐ FMLA leave records
☐ Work schedule records

Benefits Information:
☐ Health insurance enrollment records
☐ Summary Plan Description (SPD)
☐ Benefits election forms
☐ COBRA notices
☐ Disability insurance information
☐ Life insurance information
☐ Retirement plan records (401k, pension)
☐ Workers' compensation claims

Other Records:
☐ Union/collective bargaining information
☐ Training records
☐ Promotion history
☐ Termination/separation documentation
☐ Exit interview records
☐ Return to work documentation
☐ Light duty/accommodation records
☐ Other: [________________________________]

SECTION 6: PURPOSE OF DISCLOSURE

This authorization is requested for the purpose of:

☐ Documenting lost wages claim in personal injury matter
☐ Establishing pre-injury earning capacity
☐ Documenting reduced earning capacity
☐ Verifying employment status and income
☐ Legal representation in connection with injuries sustained on [DATE OF INCIDENT]
☐ Other: [________________________________]

SECTION 7: THIRD PARTY VERIFICATION

I authorize the above employer to verify the following information verbally or in writing to the Authorized Recipient or their designated agents:

☐ Dates of employment
☐ Job title and duties
☐ Salary/wage information
☐ Hours typically worked
☐ Days missed due to injury
☐ Return to work status
☐ Ability to perform job duties
☐ Light duty/restrictions
☐ Benefits status
☐ Other: [________________________________]

SECTION 8: SELF-EMPLOYMENT RECORDS (if applicable)

☐ This section applies

If self-employed, I authorize release of:

From Accountant/CPA:
Name: [________________________________]
Address: [________________________________]
Phone: [________________________________]

Records requested:
☐ Tax returns (personal and business)
☐ Profit and loss statements
☐ Business financial statements
☐ 1099 forms
☐ Schedule C/Schedule K-1
☐ Quarterly estimated tax payments
☐ Other: [________________________________]

From Financial Institution:
Bank Name: [________________________________]
Account Number: [________________________________]

Records requested:
☐ Business bank statements
☐ Deposit records
☐ Business loan documents
☐ Other: [________________________________]

SECTION 9: EXPIRATION AND REVOCATION

Expiration:

This authorization shall remain valid until:

☐ [SPECIFIC DATE]
☐ One (1) year from date of signature
☐ Conclusion of legal matter, including all appeals
☐ Upon written revocation

Right to Revoke:

I understand that I may revoke this authorization at any time by providing written notice to the employer(s) listed above. Revocation will not affect any disclosures made prior to receipt of the revocation notice.

SECTION 10: EMPLOYEE ACKNOWLEDGMENTS

I understand and acknowledge that:

☐ I am authorizing the release of confidential employment records.

☐ This information will be used in connection with a legal claim.

☐ Once released, this information may become part of court records or disclosed during litigation.

☐ I have the right to refuse to sign this authorization, but failure to do so may impact my ability to prove lost wages or earning capacity.

☐ I am entitled to receive a copy of this authorization upon request.

☐ I may request a copy of any records released pursuant to this authorization.

☐ The employer may charge reasonable copying fees as permitted by law.

☐ This authorization does not guarantee that the employer will release all requested records.

SECTION 11: ADDITIONAL AUTHORIZATIONS

Verification of Future Employment Status:

☐ I authorize the employer to provide ongoing updates regarding my employment status, work restrictions, and return to work progress to the Authorized Recipient until this authorization expires or is revoked.

Third-Party Payroll Provider:

If payroll is processed by a third-party provider:

Company Name: [________________________________]
Address: [________________________________]
Phone: [________________________________]

☐ I authorize this payroll provider to release compensation records to the Authorized Recipient.

SECTION 12: SIGNATURE

By signing below, I authorize the release of my employment records as described above.

Employee Signature: _________________________________

Printed Name: _________________________________

Date: _________________________________

Witness (if required):

Witness Signature: _________________________________

Printed Name: _________________________________

Date: _________________________________

SECTION 13: NOTICE TO EMPLOYER

TO: Human Resources / Payroll Department

FROM: [LAW FIRM NAME]

RE: Employment Records Request
Employee: [________________________________]
SSN (last 4): XXX-XX-[____]
DOB: [________________________________]

Pursuant to the enclosed authorization, please provide the following employment records:

☐ Pay stubs for period: [________] to [________]
☐ W-2 forms for years: [________]
☐ Attendance/absence records for period: [________] to [________]
☐ Personnel file
☐ Employment verification letter including:
- Dates of employment
- Job title and duties
- Current salary/wage rate
- Average hours worked per week
- Days missed due to injury (from [DATE] to present)
- Current work status (full duty/light duty/off work)

Please send records to:
[LAW FIRM NAME]
[ADDRESS]
[CITY, STATE ZIP]
Attn: [________________________________]
Fax: [________________________________]
Email: [________________________________]

Questions: Please contact [________________] at [________________]

Thank you for your prompt attention to this request.

VERIFICATION OF EMPLOYMENT FORM

EMPLOYMENT VERIFICATION

Employee Name: [________________________________]

Social Security Number (last 4): [____]

Completed By:
Name: [________________________________]
Title: [________________________________]
Phone: [________________________________]
Date: [________________________________]

EMPLOYMENT INFORMATION:

COMPENSATION INFORMATION:

ABSENCE INFORMATION:

Date Employee Last Worked Before Injury: [________________]

Date Employee Returned to Work: [________________] ☐ Not Yet Returned

Total Work Days Missed Due to Injury: [________________]

Current Work Status:
☐ Full duty - no restrictions
☐ Light duty with restrictions
☐ Off work entirely
☐ Reduced hours: [____] hours per week
☐ Other: [________________________________]

Work Restrictions (if any): [________________________________]

BENEFITS INFORMATION:

ADDITIONAL COMMENTS:
[________________________________]
[________________________________]

Employer Signature: _________________________________

Date: _________________________________

Company Stamp/Seal:

LAW FIRM USE ONLY