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Travel reimbursement request form 2026
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- Click ‘Get Form’ to open the travel reimbursement request form in the editor.
- Begin by filling in your worker information. Include your name, date of injury, home address (not a PO Box), city, state, zip code, and phone number.
- Select the reason for travel by checking only one type of travel per form: medical visit, vocational services, or attending a retraining class.
- In the travel information section, indicate whether you have attached your expense receipts by selecting 'Yes' or 'No'.
- Complete each column for your travel details: Date traveled, travel code (refer to the provided codes), cities traveled from and to, provider name and reason for visit, total miles traveled round trip, and expense cost.
- Ensure that you obtain the required signatures from the provider or office staff for verification of each appointment date.
- Finally, sign the form yourself to confirm that these expenses are related to your workers’ compensation claim and that you have not been reimbursed for them.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2019 | 4.9 Satisfied (37 Votes) |
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wa lni travel reimbursement
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