North Dakota > Workers Comp
Request For Personal Reimbursement SFN 18435 - North Dakota
| Request For Personal Reimbursement Form. This is a North Dakota form and can be used in Workers Comp . |
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REQUEST FOR PERSON NAL REIMBU URSEMENT T CLAIMS DIVISION D SFN 18435 (08/2012) 1600 EAST CENTURY AVENUE, SUITE 1 T PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (he earing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 d forceSafety.com www.Workf Ple ease print or type using black or blue ink. Reimb r b e bursement m be delay if this for is not fille out may yed rm ed completely. WSI reimburse at the allo W es owed rate. See the revers side of th form for reimburseme se his ent guidelines. Injure Worker's Na ed ame Claim N Number R REIMBURSEM MENT INFORM MATION DAT OF TRIP TE STREET ADDR RESS AND CITY YOU Y DEPA ARTED FROM TRIP 1 TRIP 2 Home Work Other O STRE EET ADDRESS AND CITY YOU DROVE TO U ROUND TRI MILEAGE FR IP ROM ST TREET ADDRES TO STREET ADDRESS SS A N NAME OF DOCT TOR OR HEALTH CARE PROVIDER SEEN AND NAME OF FACILITY F DATE AND TIM YOU LEFT HOME ME H TO ATTEND THIS APPOINTM T MENT DA ATE AND TIME OF YOUR APPO O OINTMENT DATE AND TIME YO E OUR APPOINTMENT ENDED DATE AND TIME YOU ARRIVED T BACK HOME AFTER THE TRIP T MEA EXPENSE INCURRE - Receipts are not need AL ES ED s ded. Please iinclude the d date of each m meal and indicate if it was s brea akfast, lunch or supper. o D Date Br reakfast Lu unch Su upper Br reakfast Lu unch Su upper Ci State ity, Date D Date Ci State ity, Date Breakfast Lunch Supper Breakfast Lunch Supper City, State Date City, State Date Breakfast Lunch Supper Breakfast Lunch Supper City, State City, State MOT TEL EXPENSES INCURRED - Receipts are required. (I e Include date, motel name, and amount of tax) D Date Am mount Name of N Hotel Date Amount Name of Hotel Date Amount Name of Hotel OTHER EXPENSES INCURRED - Itemized rec ceipts are req quired. Reimb bursement of luggage fees requires a receipt from f s the a airline. Date Amount Service Date Amount t Service I dec clare that the statements on this form ar true and I understand th falsifying m claim cons re u hat my stitutes a Clas A ss Misd demeanor. Pe ersons falsifying claims in this regard fo t orfeit any addiitional benefit relative to t ts this work injur ry. Signa ature Date C C40a American LegalNet, Inc. www.FormsWorkFlow.com REIMBURSEMENT GUIDELINES Requests for reimbursement must be received within one year of the date the expense was incurred. If you choose to seek medical treatment outside your local area where care is available, travel reimbursement may be denied. MILEAGE · · · · Mileage is calculated from street address to street address. Mileage is reimbursed when the distance traveled is 50 miles one way or greater, or the total mileage equals or exceeds 200 miles in a calendar month. Mileage will be paid at the current rate. You may contact a WSI Customer Service representative for the current rate at 1-800-777-5033 or 701-328-3800. Receipts are not needed. MEALS · · Breakfast is reimbursed when travel requires you to depart from your home before 7:00 a.m. Supper expense is reimbursed when travel prohibits you from returning home before 7:00 p.m. Meal reimbursement amounts: In-State Meals Breakfast Lunch Supper $6.00 $9.00 $15.00 Out-of-State meals are reimbursed at the appropriate state rate. · Receipts are not needed. LODGING · Motel expense is reimbursed when travel requires you to depart from your home before 7:00 a.m., your total travel time is over 8 hours, your doctor determines it is medically necessary to stay overnight, or it is approved by your adjuster. Motel reimbursement amounts: In-State Lodging $69.30 + tax per day Out-of-State Lodging $77.00 + tax per day · · Itemized receipts are required. · WSI pays the actual cost of lodging, when the actual cost is less than the reimbursement amount. Additional forms can be found at www.workforcesafety.com or by calling customer service. American LegalNet, Inc. www.FormsWorkFlow.com
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