Fillable Mileage Reimbursement Request Form printable pdf download

Mileage Reimbursement Request Form

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MILEAGE REIMBURSEMENT REQUEST FORM

WORKERS’ COMPENSATION

P.O. Box 2805

Clinton, IA 52733-2805

Claimant:

Address:

SS#:

Claim #:

Phone:

Date of

Injury:

EMPLOYER:

Round Trip

Date

From Location

To Location

Purpose

Mileage

____________

TOTAL MILES

$.53/ MILE

____________

SIGNATURE ___________________________________

AMOUNT DUE

Rule 18-6( E) Mileage Expenses

The payer shall reimburse an injured worker for reasonable and necessary mileage expenses for travel to and from medical appointments and reasonable

mileage to obtain prescribed medications.The reimbursement rate shall be $0.53 cents per mile. The injured worker shall submit a statement to the payer

showing the date(s) of travel and number of miles traveled, with receipts for any other reasonable and necessary travel expenses incurred.

Mileage reimbursement is reimbursed at the rate that was in effect on the date the mileage was incurred.

Effective Date

Mileage Rate (per mile)

Effective 01/01/12

47 cents

Effective 01/01/13

52 cents

Effective 01/01/14

53 cents

Effective 01/01/15

53 cents