Luba form 2026

1. Click ‘Get Form’ to open the luba form in the editor.
2. Begin by entering your name, home address, and phone number in the designated fields at the top of the form.
3. Next, input the date of the accident and your Social Security number. Ensure accuracy as this information is crucial for processing your claim.
4. Fill in your employer's name in the appropriate field.
5. List each trip taken for mileage reimbursement. Specify starting and ending locations, including addresses for doctors, pharmacies, or hospitals visited.
6. Calculate and enter the round trip mileage for each trip in the provided section.
7. Sum up all trips and enter the total mileage at the end of the form.
8. Finally, sign and date the form to certify that all information is true before mailing it to LUBA Workers’ Comp at the specified address.

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