Itemized Statement Of Charges For Travel {25T} | Pdf Fpdf Docx | North Carolina

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Itemized Statement Of Charges For Travel {25T} | Pdf Fpdf Docx | North Carolina

Itemized Statement Of Charges For Travel {25T}

This is a North Carolina form that can be used for Workers Comp.

Alternate TextLast updated: 7/15/2019

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F ORM 25T 01 /201 9 P AGE 1 OF 1 N OTICE TO I NJURED E MPLOYEE : T HIS FORM SHOULD BE R ETURNED TO THE C ARRIER AT THE ADDRESS ABOVE FOR PAYMENT . F OR A SSISTANCE , C ALL : N.C. I NDUSTRIAL C OMMISSION M AIN T ELEPHONE : (919) 807 - 2500 H ELPLINE : (800) 688 - 8349 F ORM 25T North Carolina Industrial Commission IC File # I TEMIZED S TATEMENT OF C HARGES FOR T RAVEL Emp. Code # Carrier Code # The Use o f This Form Is Required Under t he Provisions of t he Workers' Compe nsation Act Carrier File # Employer FEIN ( ) - Employer's Name Telephone Number Address City State Zip City State Zip Insurance Carrier ( ) - ( ) - Home Telephone Work Telephone Carrier's Address City State Zip ( ) - ( ) - Carrier's T elephone Number Fax Number Employees are entitled to reimbursement of $0. 58 per mile for travel for medical treatment, provided they travel 20 miles or more roundtrip, starting January 1, 201 9 . Special consideration will be given to employees who are totally disabled. No reimbursement is allowed for trips to purchase medications or supplies unless medically necessary. These items must be purchased on visits to medical providers (G .S. 247 97 - 25). DATE NAME OF MEDICAL PROVIDER CITY TOTAL MILES ROUNDTRIP / / / / / / / / / / OTHER EXPENSES If overnight stay is necessary, the following items will be approved as submitted. (Receipts must be furnished for car Total motel expense ( actual, up to $ 71 . 2 0 per day in - state or $84.10 per day out - of - state ): Total Miles: Total meal expense ($ 8 . 4 0 Breakfast, $11.00 Lunch, and $1 8 . 9 0 in - state or $21.60 out - of - sta te Dinner ): X [mileage rate]* Total parking & cab expense (actual charge): Other expenses: Total for other expenses: Total all expenses: *Prio r mileage rates are as follows: (a) $0. 5 4 5 for 2018; ( b ) $0. 5 35 for 201 7 ; ( c ) $0. 5 4 for 201 6 ; ( d ) $0. 575 for 2015 ; ( e ) $0.56 for 2014 I hereby certify that I have incurred all expenses listed above as a result of my workers' comp ensation injury. Employee signature Employee: Mail your bill in duplicate promptly to employer and/or insurance carrier Employer or Carrier/Administrator: Travel may be reimbursed directly to the employee. It is not necessa ry to submit bills to the Commission for approval. Pay and retain copy in carrier's file. American LegalNet, Inc. www.FormsWorkFlow.com

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