Workers’ Compensation Reimbursement Forms

When it comes to workers’ compensation there can be many confusing laws, creating a hard to navigate industry for newly injured workers. Essentially, workers’ compensation is a legal system and many times requires consulting with an attorney. Worker’s compensation law varies on a state-by-state basis. One law that varies by state is your entitlement to a transportation reimbursement. Below we have provided the various workers’ compensation transportation reimbursement forms for US states.

1. California
http://www.dir.ca.gov/dwc/i&a_mileageform.pdf

2. Pennsylvania
https://cjsmithlaw.com/wp-content/uploads/2015/01/MILEAGE.pdf

3. Connecticut
http://wcc.state.ct.us/download/acrobat/mileage.pdf

4. Florida http://www.myfloridacfo.com/division/risk/WorkersCompensation/Documents/07.Mileage_Reimbursement_Form_03-2013.pdf

5. Georgia
http://sbwc.georgia.gov/sites/sbwc.georgia.gov/files/imported/SBWC/Files/SectionXIIINonEmergencyTransportationDraft9.pdf

6. Idaho
http://www.iic.idaho.gov/forms/Form%20432(1)%20070215_updated.pdf

7. Maine
http://www.maine.gov/wcb/forms/WCB-206.pdf

8. Massachusetts
http://www.mass.gov/lwd/workers-compensation/forms/form-list-alphabetical/vr-travel-voucher.pdf

9. Michigan
http://www.michigan.gov/documents/wca/Travel_Reimbursement_Rates_478162_7.pdf

10. Minnesota
https://www.dli.mn.gov/WC/PDF/mq03.pdf
http://www.dli.mn.gov/WC/Pdf/annladj.pdf

11. Virginia
http://www.vwc.state.va.us/sites/default/files/documents/Min-Max-Benefits_2.pdf

12. Texas
http://www.tdi.texas.gov/forms/dwc/dwc048trvlreim.pdf

13. Washington
http://lni.wa.gov/forms/pdf/F245-145-000.pdf

14. Nevada
http://naiw.nv.gov/uploadedFiles/naiwnvgov/content/Medical/d-26.pdf

15. New Mexico
http://www.workerscomp.state.nm.us/travel.php

16. New York
http://www.wcb.ny.gov/content/main/forms/c257.pdf

17. North Carolina
http://www.ic.nc.gov/forms/form25t.pdf

18. North Dakota
https://www.workforcesafety.com/sites/default/files/workers/C40a.pdf

19. Missouri
http://oa.mo.gov/sites/default/files/mileagereimbursement.pdf

20. Oklahoma
http://www.owcc.state.ok.us/PDF/Mileage%20Rate%20History%20Chart.pdf

21. Oregon
http://www.wcd.oregon.gov/policy/bulletins/docconv_12544/3921.pdf

22. South Carolina
http://www.wcc.sc.gov/welcomeandoverview/compensationrates/Pages/default.aspx

23. Texas
http://www.tdi.texas.gov/forms/dwc/dwc048trvlreim.pdf

24. Vermont
http://labor.vermont.gov/wordpress/wp-content/uploads/milereimbformtoolFillIn.pdf

25. Virginia
http://www.vwc.state.va.us/sites/default/files/forms/Claim-for-Benefits-Form.pdf

26. Washington
http://www.lni.wa.gov/forms/pdf/F245-145-000.pdf

27. West Virginia
http://www.wvinsurance.gov/Portals/0/pdf/wc/notices/travel-expense-notice.pdf

These forms were very difficult to locate. If you can find any forms we missed, feel free to share them or send us a message.

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