Request For Reimbursement Of Expenses For Travel And Lost Wages
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Request For Reimbursement Of Expenses For Travel And Lost Wages Form. This is a Nevada form and can be use in Workers Comp.
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Tags: Request For Reimbursement Of Expenses For Travel And Lost Wages, D-24, Nevada Workers Comp,
REQUEST FOR REIMBURSEMENT OF EXPENSES FOR TRAVEL AND LOST WAGES
Pursuant to NRS 616C.365 and 616C.477
Claim No:
Date of Injury:
Insurer's Name:
Injured Employee's Name:
Social Security No.
Present Employer:
Phone No:
Date of Hearing/Treatment:
Time of Hearing/Treatment: Begin
From:
Place of Employment
End
Residence*
(Check One)
*DO NOT USE RESIDENCE FOR
EXTENDED TRAVEL BENEFIT
Address:
To: Place of Hearing/Treatment:
Address:
FOR TRAVEL AND LOST WAGES FOR HEARINGS Pursuant to NRS 616C.365
FOR INSURER'S USE
Total Miles Traveled (One Way) . . ..
Miles X 2 X
per mile =
Food . . . . . . . . . . . . . . . . . . . . . . . . . .
Lodging . . . . . . . . . . . . . . . . . . . . .
Lost Wages . . . . . . . . . . . . . . . . . . . . .
Total Expenses . . . . . . . . . . . . . . . . ..
Total $
LOST WAGES COMPENSATION FOR EXTENDED MEDICAL TRAVEL
Pursuant to NRS 616C.477
Employer at time of injury:
FOR INSURER'S USE
Total Miles Traveled (One Way) . . . . . . ..
Qualify?
Total Time Absent from Employment . . ..
TTD
YES or
50% or
NO
100 %
TTD RATE $
I declare under penalty of perjury that the above amounts were necessarily incurred and that they are
true and correct to the best of my knowledge.
Date
Signature of Injured Employee
D-24 (rev. 6/2006)
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