Surrogate Lost Wage Reimbursement Form

Form to request reimbursement for lost wages.
  • Please enter the name of the person who needs to be reimbursed 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.
  • The first day of missed work.
    Date Format: MM slash DD slash YYYY
  • Last Day of Lost Wages
    Date Format: MM slash DD slash YYYY
  • Please provide the total number of days missed from work.
  • Please provide the total number of hours missed per day.
  • Please provide the total number of hours requested for reimbursement.
  • Please provide your regular hourly wage or weekly salary.
  • 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.
  • 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
  • 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.
  • 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
  • Please provide any additional details here.
  • 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.
  • Please provide an email address where we may contact you with questions.
  • This field is for validation purposes and should be left unchanged.

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