Transportation Cost Encumbrance
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Transportation Cost Encumbrance Form. This is a Washington form and can be use in Self Insurance Workers Comp.
Loading PDF...
Tags: Transportation Cost Encumbrance, F245-375-000, Washington Workers Comp, Self Insurance
Department of Labor and Industries
This form must be completed by the Vocational
Counselor assigned by either State Fund or
Self Insurance.
TRANSPORTATION COST ENCUMBRANCE
Original
**** Counselor is responsible for sending
a copy of this form to each vendor ****
Claimant:
Date
Vendor Name
Vendor Name
Modification
Revised
Claim Number
Vendor Name
Vendor Name
Total
Funds
Billing Category
and Code
Provider No.
Provider No.
Provider No.
Provider No.
From:
To:
From:
To:
From:
To:
From:
To:
Mileage - 0301R
Parking - 0302R
Bridge & Ferry
Tolls - 0303R
Commercial
Transportation - 0304R
Vendor Funds
Allocated
Dates of Service
» » » » » » » » » » » » »
Total Transportation Funds Allocated:
Mileage Calculation
Address training site A
Address training site B
1st, Miles in a round trip (Worker's street
address to site A by most direct route).
2nd, Multiply miles by the actual
x
training days.
1st, Miles in a round trip (Worker's street
address to site B by most direct route).
2nd, Multiply miles by the actual
x
training days.
3rd, Multiply total in line 2 by current
reimbursement rate x
3rd, Multiply total in line 2 by current
reimbursement rate x
Reimbursement to site A =
Reimbursement to site B =
Reimbursement to site A
Total reimbursement requested (Site A+Site B) =
NOTICE: Please attach a copy of this form to the Injured Worker's Travel Expense Voucher form (yellow),
when submitting for reimbursement.
Company
Phone No.
Assigned Vocational Counselor:
Date
FAX No.
Signature
For Dept Use Only
Vocational Services Specialist
Not
Approved
Approved
Date
Phone No.
F245-375-000 transportation cost encumbrance 01-2008
For workers with training plans approved before 1-1-2008, use form F245-360-000
Signature
INDEX: VPLAN
American LegalNet, Inc.
www.FormsWorkFlow.com
