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State Accident Fund Mileage Reimbursement Form Injured Worker Name: Home Address: Employer:Claim No: Date of Accident:*Mileage must be more than 10 miles round trip* *Mileage will not be paid for

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How to fill out mileage reimbursement form injured

01

Start by entering your personal information in the designated fields, such as your name, address, and contact details.

02

Indicate the date of the accident or injury and provide a brief description of the incident.

03

Include the starting point and destination of each trip for which you are claiming mileage reimbursement.

04

Record the total number of miles traveled for each trip and calculate the total mileage.

05

Attach supporting documents such as receipts or invoices for any expenses related to transportation or medical treatment.

06

Sign and date the form to certify the accuracy of the information provided.

07

Submit the completed form to the appropriate authority or department for processing.

Who needs mileage reimbursement form injured?

01

Anyone who has been injured and is seeking reimbursement for mileage expenses incurred due to the injury needs the mileage reimbursement form injured.

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What is mileage reimbursement form injured?

The mileage reimbursement form injured is a document used to request reimbursement for travel expenses related to injuries.

Who is required to file mileage reimbursement form injured?

Individuals who have incurred travel expenses due to injuries and wish to be reimbursed are required to file the mileage reimbursement form.

How to fill out mileage reimbursement form injured?

To fill out the mileage reimbursement form injured, one must provide details of the injury, date of travel, starting and ending locations, and total mileage.

What is the purpose of mileage reimbursement form injured?

The purpose of the mileage reimbursement form injured is to ensure that individuals are properly reimbursed for travel expenses incurred as a result of injuries.

What information must be reported on mileage reimbursement form injured?

Information such as injury details, date of travel, starting and ending locations, and total mileage must be reported on the mileage reimbursement form injured.

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