California form mileage 2025

1. Click ‘Get Form’ to open the California Form Mileage in the editor.
2. Begin by entering your claim number and the injured worker’s name at the top of the form.
3. Fill in the date of travel, and specify where you traveled from, including the address.
4. Next, indicate your destination by providing the name and address of your doctor, hospital, or therapist.
5. Record the total miles traveled for your round trip. Ensure accuracy as this affects reimbursement.
6. Document any parking fees and tolls incurred during your travel. Input these amounts in their respective fields.
7. Calculate your total reimbursement requested by summing up all expenses and multiplying mileage by $0.56 per mile.
8. Finally, sign and print your name at the bottom of the form before submitting it to your insurance company.

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