Surrogate Lost Wage Reimbursement Form

Surrogate's Name*Required
Intended Parent(s)' Name*Required
Agency Name
For Whom Are We Paying Lost Wages?*Required
Please enter the name of the person who needs to be reimbursed lost wages.
The Person for Whom Lost Wages are Being Paid is:*Required
- The Gestational Carrier/Surrogate
- The Gestational Carrier's Spouse or Partner
- A Companion
Reason for Incurring Lost Wages*Required
Please identify the reason for requesting lost wages by selecting a box below. If you select other, please provide additional information in the Comment Box at the bottom of the form.
- Bed Rest Order or Work Restriction
- Delivery
- Doctor's Appointment
- Embryo Transfer
- Monitoring Appointment (including labwork)
- Other
Beginning Date of Lost Wages*Required
The first day of missed work.
Ending Date of Lost Wages*Required
Last day of lost wages
Total Number of Days of Lost Wages*Required
Please provide the total number of days missed from work.
Number of Hours Missed Per Day*Required
Please provide the total number of hours missed per day.
Number of Hours Requested*Required
Please provide the total number of hours requested for reimbursement.
Regular Hourly Wage or Weekly Salary*Required
Please provide your regular hourly wage or weekly salary.
Documentation Provided to Evidence Wages*Required
Please select the type of documentation you are submitting to help us establish the amount of your lost wages or evidence of actual lost wages as may be required by your surrogacy contract.
- Paystubs
- Letter from Employer Confirming Hourly Rate and Schedule
- Other Form of Documentation
- No Paystub or Documentation Required by Contract
Wage Documentation
Please attach your two most recent paystubs or any other documentation evidencing your lost wages as required by your surrogacy contract.
Drop files here or
Max. file size: 64 MB.
Medical Documentation Provided for Lost Wages, Bed Rest, Work Restriction
All surrogates must submit written confirmation of their bed rest order from their physician or other work restrictions, or other documentation of attendance at a medical appointment or embryo transfer procedure. Please select the type of documentation you are providing from the list above. If you select Other from the list please provide an explanation in the comment box below.
- Physician's Written Order or Instructions
- FMLA Paperwork or Employer Certification for Requested Leave
- Bill from Medical Visit
- Discharge Papers or Instructions from IVF Clinic, Hospital, or ER
- Other
Bed Rest or Work Restriction Documentation
Please attach a copy of your written documentation supporting your lost wages due to bed rest or other work restriction (for example your discharge instructions from your embyro transfer or instructions from a monitoring appointment; your FMLA paperwork for post-partum leave; or Doctor's written order for bed rest due to pregnancy complication).
Drop files here or
Max. file size: 64 MB.
Comments
Please provide any additional details here.
Confirmation of Form Submission -- Please Confirm the Following*Required
Have you provided all information Stork Escrow needs in order to process your request? Forms submitted and not properly documented will not be processed and thus delay the time in which you receive your reimbursement. Please use the following checklist to ensure you are submitting a properly completed form for reimbursement of an expense.
- I have attached a copy of my doctor's note or other evidence of my lost wages.
- I have attached paystubs or other proof of my wages as may be required by my surrogacy agreement.
- I have provided the number of hours I missed from work.
- I have provided the dates I missed work.
- I have provided my hourly or weekly salary.
Email Address*Required
Please provide an email address where we may contact you with questions.
Enter Email Confirm Email
Name of Person Completing Form*Required
Form Consent*Required
I understand that by submitting this form I give consent to Stork Escrow to collect my personal information in accordance with their privacy policy and to contact me at the email address I listed above.
I agree to the Stork Escrow privacy policy.
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