Surrogate Lost Wage Reimbursement Form

This is the form to request reimbursement for lost wages. Please complete the following information to the best of your ability. Leave anything blank that does not apply.

All fields marked with * are required. Once the form is submitted you will be taken to a confirmation page. If you do not see this confirmation, you have most likely missed a required field. Please read through the form, fill in any missing entries, and try submitting again.

Step 1 of 2

Surrogate's Name*

Please enter your name or that of the surrogate to whom reimbursement should be issued.

Intended Parent(s)' Name*

Please provide the name(s) of the intended parent(s).

Agency Name

Please provide the name of your surrogacy agency if you are working with one.

The Person for Whom Lost Wages are Being Paid is:*

The Gestational Carrier/Surrogate

The Gestational Carrier's Spouse or Partner

A Companion

What Type of Request is This?*

Are you submitting for DAILY lost wages (i.e., one day of lost wages) or WEEKLY lost wages (i.e., 5 continuous days of lost wages)?

Daily

Weekly

Both Daily and Weekly

Daily Lost Wage Reimbursement Requests

Please click the button below to add each request you have for a SINGLE day of lost wages.

Date the Lost Wages Were Incurred	Actions

There are no Daily Lost Wages.

Weekly Lost Wage Reimbursement Requests

Please click the button below to add each request you have for WEEKLY lost wages (i.e., 5 continuous days of lost wages). Please note we can only reimburse you for wages that actually have been lost, not those you will incur in the future.

Beginning Date of Lost Wages	Actions

There are no Weekly Lost Wages.

Total Days of Lost Wages*

Please confirm the total number of DAYS of lost wages you are requesting be reimbursed.

Total Hours of Lost Wages*

Please confirm the total number of HOURS of lost wages you are requesting be reimbursed.

Documentation Provided to Evidence Wages*

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: 100 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: 100 MB.

Comments

Please provide any additional details here.

Confirmation of Form Submission -- Please Confirm the Following*

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.

Name of Person Completing Form

Please enter your name, if not already provided above.

Email Address of Person Completing Form*

Please provide an email address where we may contact you with questions.

Enter Email Confirm Email

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