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Sample Wage Loss Request Cover Letter To Employer

Facsimile: {(xxx) xxx-xxxx}

{Employer Company Name}
Attention: Human Resources
{Address 1}
{Address 2}
{City},{State} {ZIP}


Re:     Our Client/Your Employee:     {Name of Client/Employee}
Date of Birth:                               {xx/xx/xxxx}
           Date of Accident:                  {xx/xx/xxxx}

Dear Sir or Madam:

This law firm has been retained to represent {name of client/employee} with respect to injuries and damages {he/she} sustained in an accident as referenced above. We are not making a claim against you or your company. However, our {client/your employee} has advised us that {he/she} missed time from work, either paid or unpaid due to this accident.

In order to assist us in representing your employee, we request that you provide us with information regarding the time {he/she} missed from work related to this accident (i.e. accident recovery, doctor/physical therapy appointments, not feeling well). We are requesting this information even if {he/she} was paid or compensated for the time missed.

I have enclosed a form for your use or you may use one of your own that contains your company letterhead. We have enclosed a signed release which permits you to provide us with this information. We request you respond with the utmost timeliness in order to meet certain deadlines no later than {insert date}. Please feel free to attach any documents to support the information you provide to us.

If you have any questions, please feel free to contact our office. Thank you in advance for your attention and cooperation regarding this request.



{name of attorney}


Arizona Personal Injury Complaints

Arizona Interpleader Actions

Arizona Discovery Documents

Arizona Pre-Litigation Documents

Disclaimer: The information and forms on this site are for illustrative purposes only. The information is not intended to be used by anyone other than a licensed Arizona attorney familiar with Arizona personal injury law. The forms and the information contained in them may not be up-to-date and must be independently reviewed, cite checked, rule checked, and otherwise verified by a licensed Arizona attorney. The information contained in the forms on this website cannot and must be relied on for the purposes of filing legal documents or otherwise pursuing a claim. If you have any questions about this, please contract and attorney at or by calling 602-833-1274.