MILEAGE REIMBURSEMENT FORM Claimant Name Claimant Address Date of Travel Date of Accident Name of Medical Facility (including Pharmacies) Round-Trip Mileage To & From Residence I hereby certify or affirm that the above mileage was incurred by me as necessary traveling expenses related to those medical facility visits pursuant to my workers’ compensation case. Claimant’s Signature Today’s Date American LegalNet, Inc. www.FormsWorkFlow.com