Daily Mileage Log Template
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1750 Park of Commerce Blvd.
Suite # 205
Boca Raton FL 33487
Fax # 561-988-2035
MILEAGE LOG
NAME:________________________ CLAIM #: _____________
From
Destination/
To
Total
DATE
(Home/Work)
Purpose
(Home/Work)
Miles
example
work
Doctor (name) visit
work
0
TOTAL MILEAGE ___________
Reimbursed x $ .445
Any person who, knowingly and with intent to injure, defraud, or deceive any
employer or employee, insurance company, or self-insured program, files a
statement of claim containing any false or misleading information is guilty of a
felony of the third degree.
Signature_________________________________ Date_______________
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