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California state fund mileage form 2013-2026
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How to use or fill out California State Fund Mileage Form 2013
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the Injured's Name and Claim Number at the top of the form. This information is crucial for processing your reimbursement request.
- In the 'Rate For Travel' section, refer to the mileage rates applicable for your travel dates. Ensure you select the correct rate based on when you traveled.
- Fill in each trip's details, including the date, starting address, destination (doctor or medical facility), and round trip mileage. Be precise to avoid delays in processing.
- Include any additional expenses such as parking fees or tolls in their respective sections. Attach receipts for these expenses to support your claim.
- Finally, sign and print your name at the bottom of the form, along with the date. Keep a copy for your records before submitting it to your assigned claims adjuster or one of the State Fund Claims Processing Centers.
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state fund mileage reimbursement form
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