Form Dfs-F2-Dwc-1 - First Report Of Injury Or Illness Template Page 9
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9Cannon Cochran Management Services, Inc.
866‐291‐
‐660‐
‐477‐
Please fax or email the completed form to the adjuster for handling. Thank you.
REQUEST FOR MILEAGE REIMBURSEMENT
NAME:
EMPLOYER:
Nova Southeastern University
CLAIM NUMBER:
CLAIMANT ADDRESS:
WORK ADDRESS:
DATE OF INJURY:
ADJUSTERS: Terri Krepps
Date of Visit
Name of Medical Facility (Including Pharmacies)
Roundtrip Miles
Residence or
with address
Work (Please
indicate)
Total Miles: ___________________________ x ____0.45___________ = $ ________
I hereby certify or affirm that the above mileage was incurred by me as necessary traveling expenses related to those medical facility
visits pursuant to my workers’ compensation case.
______________________________
___________________
Signature
Date
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