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Lost Wages/Earnings lost per week X Lost Wage Total Wkly Wage Wks out work 3. Did you miss more than one week of work Yes No If yes your physician must complete the DISABILITY VERIFICATION Form. 4. LOST WAGES/EARNINGS CLAIM FORM THIS FORM IS TO BE COMPLETED BY THE VICTIM CVR NUMBER Victim Name Claimant Name Your claim investigator is Phone NOTE The CVR board does NOT guarantee full payment of your lost wages....
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