Surrogate Lost Wage Reimbursement Form

Surrogate's Name*

Intended Parent(s)' Name*

Agency Name

For Whom Are We Paying Lost Wages?*

Please enter the name of the person who needs to be reimbursed lost wages.

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

The Gestational Carrier/Surrogate
The Gestational Carrier's Spouse or Partner
A Companion

Reason for Incurring Lost Wages*

Please identify the reason for requesting lost wages be selecting a box above. 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*

The first day of missed work.

Ending Date of Lost Wages*

Last Day of Lost Wages

Total Number of Days of Lost Wages*

Please provide the total number of days missed from work.

Number of Hours Missed Per Day*

Please provide the total number of hours missed per day.

Number of Hours Requested*

Please provide the total number of hours requested for reimbursement.

Regular Hourly Wage or Weekly Salary*

Please provide your regular hourly wage or weekly salary.

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

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

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.

Email Address*

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

Enter Email Confirm Email

Name of Person Completing Form*

Form Consent*

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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Comments

This field is for validation purposes and should be left unchanged.

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