Request For Reimbursement Of Expenses For Travel And Lost Wages {D-24}

REQUEST FOR REIMBURSEMENT OF EXPENSES FOR TRAVEL AND LOST WAGES Pursuant to NRS 616C.365 and 616C.477 Claim No: Date of Injury: Insurer's Name: Injured Employee's Name: Present Employer: Date of Hearing/Treatment: Time of Hearing/Treatment: Begin From: Place of Employment Residence* End (Check One) *DO NOT USE RESIDENCE FOR EXTENDED TRAVEL BENEFIT Social Security No. Phone No: Address: To: Place of Hearing/Treatment: Address: FOR TRAVEL AND LOST WAGES FOR HEARINGS Pursuant to NRS 616C.365 FOR INSURER'S USE Total Miles Traveled (One Way) . . .. Food . . . . . . . . . . . . . . . . . . . . . . . . . . Lodging . . . . . . . . . . . . . . . . . . . . . Lost Wages . . . . . . . . . . . . . . . . . . . . . Total Expenses . . . . . . . . . . . . . . . . .. Miles X 2 X per mile = Total $ LOST WAGES COMPENSATION FOR EXTENDED MEDICAL TRAVEL Pursuant to NRS 616C.477 Employer at time of injury: FOR INSURER'S USE Total Miles Traveled (One Way) . . . . . . .. Total Time Absent from Employment . . .. Qualify? TTD YES or 50% or NO 100 % TTD RATE $ I declare under penalty of perjury that the above amounts were necessarily incurred and that they are true and correct to the best of my knowledge. Date Signature of Injured Employee D-24 (rev. 6/2006) American LegalNet, Inc. www.FormsWorkflow.com