County Of Henrico Workers' Compensation Reimbursement For Mileage Expenses

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COUNTY OF HENRICO
WORKERS’ COMPENSATION
REIMBURSEMENT FOR MILEAGE EXPENSES
Employee’s Name_______________________________________________
Employee’s Address______________________________________________
Date of Injury ___________________________________________________
Department_____________________________________________________
Date of Trip
Name of Medical Provider
Medical Provider’s Address
Round Trip Miles
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TOTAL MILES
:
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I hereby certify that the foregoing claim for reimbursement of mileage expenses is true and correct.
Signature of Claimant___________________________________
Date______________________
Form WC-5
May, 2003

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