MILEAGE REIMBURSEMENT FORM
Every time you see a doctor in connection with your industrial injury, please enter the date, starting address, doctor's name, ending
address and the round trip mileage. You will be reimbursed the mileage rate by the insurance company, as well as for all parking and
prescription expenses as long as receipts are provided.
Please enter dates chronologically
APPLICANT:
SS#:
CLAIM NO.:
Date
Starting Address
Doctor Name / Ending Address
RT-Miles