E3065 2025

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The document is a Medical Mileage Expense Form for individuals entitled to reimbursement of medical travel expenses due to industrial injuries. It provides instructions on how to complete the form, including necessary details such as claim number and injured person's name. The document outlines the reimbursement process, required receipts, and legal warnings against fraudulent claims. It also lists varying mileage rates based on travel dates.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (195 Votes)
2017	4.4 Satisfied (45 Votes)
2015	4.3 Satisfied (141 Votes)
2013	4.2 Satisfied (35 Votes)

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