Form 382-A - Application For Reimbursement Of Expenses Page 3
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4APPLICATION FOR REIMBURSEMENT OF EXPENSES
Occupational health and safety
For worker
For person accompanying the worker
Other
1. Information about the person applying for reimbursement
2. Information about worker
Surname (as shown on birth certificate) and first name
Telephone
Worker’s file No.
Home Adress, Number, Street, Apt.
Date of original event
Y Y Y Y
M M
D D
City, Province, Country
Date of recurrence,
Postal code
Y Y Y Y
M M
D D
relapse or aggravation
3. Travel Expenses (attach original receipts)
Date
Amount Claimed
Reason for travel
Distance
Method of
To
From
of round
transportation used
Physio
Occ.
Transpor-
Parking
Other (Specify)
trip (km)
Month
Day
Therapy
(√)
tation
and tolls
(√)
If the worker must be accompanied, attach the medical prescription to that effect and indicate:
Surname (as shown on birth certificate) and first name of person accompanying the worker
Telephone
Advance received
$
(if applicable)
Home Adress, Number, Street, Apt.
City, Province, Country
Signature of person
Y Y Y Y
M M
D D
applying for reimbursement
Detach and return to the CNESST
3 8 2 - A
(2017-07)
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