Dwc048 2026

1. Click ‘Get Form’ to open the dwc048 in the editor.
2. In Section A, provide your personal information. Fill in your name, date of injury, mailing address, last four digits of your Social Security Number, phone number, employer's name, and insurance carrier details.
3. Move to Section B to document travel information. For each trip over 30 miles one way for medical treatment, enter the date, travel from and to addresses, and total miles driven. Use the state mileage rate for reimbursement calculations.
4. If applicable, list any overnight stays and meal expenses in Section B. Ensure you attach receipts for these costs as they are necessary for reimbursement.
5. In Section C, certify that the information provided is correct by signing and dating the form.
6. Finally, submit the completed form to your insurance carrier within one year of incurring these costs.

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