Workers comp mileage reimbursement 2022 form-2025

1. Click ‘Get Form’ to open the workers comp mileage reimbursement 2022 form in the editor.
2. Begin by entering your Claimant Name in the designated field. This identifies you as the individual requesting reimbursement.
3. Next, input your Social Security Number. This is crucial for processing your claim accurately.
4. Fill in your Claimant Address to ensure that all correspondence regarding your claim reaches you without delay.
5. Record the Date of Accident and Date of Travel. These dates are essential for validating your mileage claims related to medical visits.
6. Specify the Name of Medical Facility (excluding Pharmacies) where you received treatment, as this supports your travel necessity.
7. Calculate and enter the Round-Trip Mileage To & From Residence. Accurate mileage is vital for proper reimbursement.
8. Finally, review the certification statement and provide your signature along with today’s date to affirm that all information is correct and truthful.

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