Claimant Travel Voucher printable pdf download

Send Completed Form To:

STATE OF WEST VIRGINIA

Zurich Insurance

STATE AGENCY

PO Box 66941

WORKERS’ COMPENSATION PROGRAM

Chicago, IL 60666-0941

FAX: 847-240-8172

Claimant Travel Voucher

TRAVEL VOUCHERS MUST BE FILED WITHIN SIX MONTHS OF DATE OF TRAVEL

1. Claimant’s Name (First, Middle, Last)

2. Claimant’s Address (Street or P.O. Box, City, State, Zip)

3. Claimant’s Social Security Number

4. Date of Injury

5. Claim Number

last four digits

6. Provider’s Name (please print)

7. Address of Point of Departure

8. Address of Point of Destination

(need physical address or closest route number)

9. Time of Departure

10. Time of Return

11. Purpose of Travel

a.m.

p.m.

a.m.

p.m.

Medical procedure codes to be used below in column 14:

Code

Description

Code

Description

Code

Description

X0910

Hotel/Motel

X9910

Mileage

X0930

Air Travel

(Occupational

Pneumoconiosis)

X0915

*Meals

X0920

Mileage

X0935

Bus/Train

X9911

*Meals (Occupational Pneumoconiosis)

X0925

Parking/Tolls

X0300

Voc. Rehab (mileage for

retraining)

X0922

Reimbursement for IME travel

X0921

Claimant travel 2

FEDTR

Federal Black Lung - Travel

physician same day

mileage

Hotel/Motel stay and Air/Bus/Train travel require prior authorization. Receipts must be attached when seeking reimbursement for all services other

than mileage.

*Meals are reimbursed for authorized OVERNIGHT travel only.

12. Date

13. Procedure Code

14. Description

15. Units/Quantity

16. Changes

17. Service Provider’s Signature

18. Claimant’s Signature

Date

19. Total Charges

The present employer is to complete the section below only if the claimant has lost wages in order to appear for a

medical examination requested by Zurich Insurance. (Not for routine medical treatment).

EMPLOYER FILL IN SECTION ONLY

20. Employer’s Business Name, Address and Phone Number

21. Date(s) of Lost Wages

22. Number Hours of Wages Lost

23. Hourly Wage

24. Amount of Lost Wages

= $

Date(s) of Lost Wages

Number Hours of Wages Lost

Hourly Wage

Amount of Lost Wages

= $

Employer’s Signature

Title

Date

06/15

SAWC-102

Claimant Travel Voucher

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