Request For Reimbursement Of Expenses {440-3921}

440-3921 - REQUEST FOR REIMBURSEMENT OF EXPENSES. Complete this form, including your workers’ compensation claim number, and send it to the insurer that processes your claim. Include copies of receipts for all items except private vehicle mileage. Incomplete requests will be returned for additional information. You must request reimbursement by whichever date is later: (a) two years from the date the costs were incurred or (b) two years from the date the claim or medical condition is finally determined compensable. www.FormsWorkflow.com