Workers Compensation Mileage Reimbursement Form
The forms are also available in individual listings.
Workers compensation mileage reimbursement form. They should also mention odometer starting and ending readings. Send the original to the insurance company and keep a copy. Do not send the original or a copy to the local workers.
In connection with the above workers compensation case you are entitled to be reimbursed for 1 drugs crutches or any apparatus properly prescribed by your doctor and for 2 fares automobile mileage or other necessary expenses going to and from your doctor s. For travel on or after 1 1 21. This is a complete listing of all division of workers compensation forms.
And request for reimbursement claimant s name wcb case no. They should mention the date of traveling origin place of travelling and the destination as well. Forms available for electronic filing are indicated by see electronic filing online forms for more information about filing your pdf form online.
Workers compensation board common forms. Simply click on the appropriate form fill out the form using your computer keyboard and the tab key or your mouse to navigate between form fields. The workers compensation law compensates you for the wear and tear on your vehicle.
See electronic filing xml format for more information about files with multiple submissions. The form 30d includes a map of connecticut s 169 cities and towns and their respective workers compensation districts as well as instructions for completing and filing this form and a listing of. Medical mileage expense form english spanish.
50 00 if filed by claimant s attorney. The mileage reimbursement forms should contain employee information like employee name and department vehicle details and purpose of visit. Nys workers compensation board centralized mailing address po box 5205 binghamton ny 13902 5205.
Print the form use the print button on or near the top of the form authorize the form if applicable provide hand written signature and mail or fax the completed form to the federal employees program office you normally send to for this process. The form 30d dependent s notice of claim to commissioner and to employer is to be completed and filed by a dependent or dependent s attorney representative for making a claim for workers compensation death benefits pursuant to section 31 306 of the workers compensation act. As of january 1 2016 the workers compensation carrier will reimburse your 54 cents per mile.
Sending information to the board. 50 00 if filed by claimant s attorney. Centralized mailing address for all workers compensation claims and claim related documents.
Mileage for reasonable travel to the pharmacy parking bridge tolls public transportation and other travel related costs are also included. If you need a medical mileage expense form for a year not listed here please contact the information and assistance unit at your closest district office of the workers compensation appeals board. Mileage rate is 56 cents 0 56 per mile.
Agreement for permanent disability disfigurement compensation please complete this form for injuries occurring after july 1 2007.