California state fund mileage form 2013-2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. 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.
4. 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.
5. Include any additional expenses such as parking fees or tolls in their respective sections. Attach receipts for these expenses to support your claim.
6. 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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