Travel Reimbursement Request Form
Mail completed forms to:
Department of Labor and Industries
PO Box 44269
Olympia WA 98504-4269
Travel Reimbursement
Request
•
You must have prior authorization from your claim manager. See WAC 296-20-1103 .
•
Read the instructions on the back before you start.
•
Traveling for an Independent Medical Examination? Find the IME travel form (F245-224-000) online at
Worker Information (please print)
Claim No.
Name (Last, First, Middle Initial)
Date of Injury
Home Address (not PO Box)
Social Security No. (For ID only)
City
State
Zip Code
Phone No.
Reason for Travel (check only one type of travel per form)
Medical visit or treatment Vocational services Attending retraining class (attach copy of
Transportation Encumbrance form [F245-375-000]
signed by your Vocational Counselor)
Travel Information – instruction and example on back
Did you attach your expense receipts? Yes No
A.
Date
(each trip)
mm/dd/yyyy
B.
Travel code
(one per line –
see back of form)
C.
From
(City)
D.
To
(city)
E.
Provider name & reason for
visit
F.
No. of miles
(round trip)
G.
Expense cost
(attach
receipts)
1.
2.
3.
4.
5.
6.
7.
Required: Signature of the provider or office staff to verify your appointment.
1.
Date
5.
Date
2.
Date
6.
Date
3.
Date
7.
Date
4.
Date
Required: Worker’s Signature
These expenses are related to my workers’ compensation claim and I have not been reimbursed for them. I
understand it is a crime to submit information I know is false. I have read and understand the instructions on
the back of this form.
Print Worker’s Name
Worker’s Signature
Date
F245-145-000 Travel Reimbursement Request 08-2014
www.Lni.wa.gov and click on Get a Form or Publication.
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Travel Reimbursement Request Form PDF
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