University of Wisconsin System
MILEAGE EXPENSESEmployee NameDate of InjuryClaim NumberFirst line provides an example of how to complete the form.Date FORMTEXT TimeFrom AddressTo AddressMileageFrom AddressTo AddressMileage1/1/202012:15 p.m.Work (123 Park Street)MD (123 Provider Lane)10MD (123 Provider Lane)Work (123 Park Street)1051339755912485FOR WORKER’S COMPENSATION EXAMINER USE ONLY__________ X _________________=$________________Total MilesCurrent Mileage RateMileage Reimbursement Due00FOR WORKER’S COMPENSATION EXAMINER USE ONLY__________ X _________________=$________________Total MilesCurrent Mileage RateMileage Reimbursement DueI certify that the above mileage was incurred by me while seeking medical attention for my work-related injury. I understand that mileage reimbursement will occur only after mileage dates given by me can be verified by Worker's Compensation.________________________________________ ___________________Signature of EmployeeDate ................
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