LODGING 0.44 Receipt Required(Maximum $120) DATE TRAVELED FROMTRAVELED TOMILESAMOUNTITEMAMOUNTAMOUNTBLDAMOUNTITEMAMOUNT TRANSPORTATION TOTAL CLAIMED OTHER EXPENSES Receipts Required (Parking, Tolls, Other) Employers are responsible for complying with Board Rules Chapter 5, Section 1.10 and Board Rules Chapter 17. NAME AND ADDRESS (PAYEE): CLAIM NUMBER: MEALS Check Meals Included(Allowed $6 breakfast, $6 lunch, $16 dinner) OTHER AUTOMOBILE NON TRAVEL-RELATED Receipts Required (SIGNATURE OF TRAVELER) (DATE) *You are entitled to mileage reimbursement pursuant to 39-A M.R.S.A. 247 315 for attendance at Board hearings. You are entitled to expenses and fees incurred for medical treatment pursuantto 39-A M.R.S.A. 247 206 or for attendance at Board appointed medical exams pursuant to 39-A M.R.S.A. 247247 312 or 611. *Complete this form and attach receipts. Send the original form and receipts to the claim administrator and keep copies for your records. Do not send the original or a copy to the Workers'Compensation Board. *If your travel costs or other expenses are not paid within 30 days, you may contact a Claims Resolution Specialist at the nearest regional office listed below. CARIBOU LESS ADVANCE BALANCE DUE (207) 941-4550 1-800-400-6856 ASSISTANCE IS AVAILABLE AT THE MAINE WORKERS222 COMPENSATION BOARD222S REGIONAL OFFICES: AUGUSTAAUGUSTA, ME 0433(207) 287-23081-800-400-6854 CARIBOU, ME 04736 BANGOR 106 HOGAN RD BANGOR, ME 04401-5638 (207) 498-6428 LEWISTON 36 MOLLISON WAY LEWISTON, ME 04240-7777 (207) 753-7700 1-800-400-6857 State of Maine Workers' Compensation Board Office of Medical/Rehabilitation Services The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers222 Compensation Board. Telephone: 1-888-801-9087 or TTY Maine Relay 711.WCB-206 (eff. 10/1/15) ROUND TRIP 1-800-400-6858 43 HATCH DR, STE 110 PORTLANDPORTLAND, ME 0410(207) 822-0840 1-800-400-6855 American LegalNet, Inc. www.FormsWorkFlow.com