REQUEST FOR PERSONAL REIMBURSEMENT CLAIMS DIVISION SFN 18435 (02/2015) 1600 E Century Ave, Ste 1 PO Box 5585 Bismarck ND 58506-5585 Telephone 800-777-5033 Toll Free Fax 888-786-8695 TTY (hearing impaired) 800-366-6888 Fraud and Safety Hotline 800-243-3331 www.workforcesafety.com Please print or type using black or blue ink. Reimbursement may be delayed if this form is not filled out completely. WSI reimburses at the allowed rate. See the reverse side of this form for reimbursement guidelines. Injured worker's name Claim number Reimbursement Information Date of trip Street address and city you departed from Home Work Other Street address and city you drove to Round trip mileage from street address to street address Name of doctor or health care provider seen and name of facility Phone number of doctor, healthcare provider, or facility, if known Date and time you left home to attend this appointment Date and time of your appointment Date and time your appointment ended Date and time you arrived Back home after the trip Trip 1 Trip 2 Meal expenses incurred - Receipts are not needed. Please include the date of each meal and indicate supper. Date City, State Date City, State Date Breakfast Breakfast Lunch Lunch Supper Supper Date City, State Date City, State Date Breakfast Breakfast Lunch Lunch Supper Supper Motel expenses incurred - Receipts are required. (Include date, motel name, and amount of tax) Date Amount Name of Date Amount Name of Date Hotel Hotel if it was breakfast, lunch or Breakfast Lunch Supper Breakfast Lunch Supper City, State City, State Amount Name of Hotel Other expenses incurred - Itemized receipts are required. Reimbursement of luggage fees requires a receipt from the airline. Date Amount Service Date Amount Service I declare that the statements on this form are true and I understand that falsifying my claim constitutes a Class A Misdemeanor. Persons falsifying claims in this regard forfeit any additional benefits relative to this work injury. Signature Date C40a American LegalNet, Inc. www.FormsWorkFlow.com Reimbursement Guidelines Requests for reimbursement must be received within one year of the date the expense was incurred. If you choose to seek medical treatment outside your local area where care is available, travel reimbursement may be denied. Mileage Reimbursement Injured worker must travel over 50 miles one way or have a total of 200 miles in a calendar month to be eligible for reimbursement. Travel must be to obtain the closest medical or hospital care. Mileage is calculated from street address to street address. The number of miles actually traveled is reputably presumed to be the least number of miles listed by MapQuest at www.mapquest.com between the start and end points of travel. Mileage will be paid at the current rate. You may contact a WSI Customer Service representative for the current rate at 1-800-777-5033 or 701-328-3800. Receipts are not needed. Mileage reimbursement is for personal vehicles, not public transportation. Meal Reimbursement Guideline: The trip must take more than 4 hours for a meal to be reimbursed. The 4 hours includes, to from and the length of the appointment. This is per ND Office of Management and Budget policy 505. Meal reimbursement is allowed only for overnight travel and other travel while away from the normal place of living residence for four hours or more. Injured workers will not be reimbursed for the first quarter if travel began after 7:00 a.m. In order to claim expenses for the second and third quarters, the injured worker must have been in travel status one hour before the start of the quarter being claimed, and travel status must extend at least one hour into the quarter being claimed. The expense allowance for each quarter of any 24-hour period effective August 1, 2013, is as follows: In-State $7.00 $10.50 $17.50 Out-of-State 20% of GSA M&IE rate 30% of GSA M&IE rate 50% of GSA M&IE rate Meal Allowance First quarter, 6 a.m. to 12 noon Second quarter, 12 noon to 6 p.m. Third quarter, 6 p.m. to 12 midnight Fourth quarter, 12 midnight to 6 a.m. Lodging Reimbursement Lodging expenses may be reimbursed if they are necessary and reasonable. Itemized receipts are required. WSI pays the actual cost of lodging, when the actual cost is less than the reimbursement amount. Additional forms can be found at www.workforcesafety.com or by calling customer service. American LegalNet, Inc. www.FormsWorkFlow.com