HTML Preview Travel Reimbursement Form For Expenses page number 1.
Travel Reimbursement Form
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Dear Sir / Madam
In order to claim reimbursement of travel expenses please complete the form in accordance with the instructions and return it to our office.
INSTRUCTIONS FOR COMPLETING THIS FORM
• Your service provider must verify attendance for medical, approved rehabilitation or hospital visits by signing the form.
• Write your name, address, claim number and employer’s name in the spaces at the top of the form.
• Fill in the details of the travel for which you are claiming in the spaces provided, ensuring that you sign and date the declaration at the bottom of the page.
• If you are claiming for fares paid for public transport, please attach tickets.
• If you are claiming for the use of your own car, show the distance travelled for each trip to the nearest 1/10th of a kilometre.
IMPORTANT: PLEASE ENSURE YOUR CLAIM NUMBER AND CLAIMS SPECIALIST NAME IS WRITTEN ON ALL RECEIPTS
Example for completing the back of this form
Date of Travel From Suburb To Name & Suburb Reason for Travel Means of Travel Cost of Distance
11/1/2005 Woodville Dr Smith Seaton Consultation Bus $1.60
11/1/2005 Seaton Woodville Return Home Bus $1.60
14/1/2005 Woodville Mr Jones Croydon Physio Car 2.3km
14/1/2005 Croydon Woodville Return Home Car 2.3km