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Mileage Reimbursement Form
Reimbursement for mileage is governed by applicable state workers’ compensation law. Please consult with your claims adjuster if you have questions regarding mileage reimbursement for your claim.
7
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1
Name
First Name
Last Name
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2
Phone Number
Please enter a valid phone number.
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3
Email
example@example.com
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4
Date of Loss / Injury
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Date
Month
Day
Year
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5
Name of Your Employer at Time of Loss
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6
Please enter trips related to your claim below
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7
Signature
I certify that the information furnished by me is true and correct and base don such information, I hereby claim reimbursement for the mileage related to my claim as indicated here.
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