Form D-26(2) - Application For Reimbursement Of Claim Related Travel Expenses
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2APPLICATION FOR REIMBURSEMENT OF CLAIM RELATED TRAVEL EXPENSES
(Pursuant to NAC 616C.150)
Please type or print and provide all the information requested. Keep and be prepared to provide, if requested, any
receipts relating to your reimbursement request.
Name (Last, First, Middle Initial)
Claim Number
Present Address (P.O. Box, Apt. No., Street)
Social Security Number
City
State
Zip
Date of Injury
Residence at time of injury:
(For Insurer's Use Only)
[__] Approved
_______________
[__] Disapproved
Initials & Date
REPORT TRAVEL WEEKLY. See reverse side of this form for the regulations under which you may be
reimbursed for claim related travel. Be aware that any misrepresentation may be considered fraud and is in
violation of Nevada law.
Daily Expense Reimbursement
Mileage
Beginning Point
Enter Travel
Leave
Allowed
Meals
of Travel
Destination
Time
Travel
Miles One
(For Insurers Use
Lodging
Date
Address
Name/Address
Time
Way
Only)
B
L
D
TOTAL
MILES:
Total of
Miles X 2 @ $
.
per Mile =
I hereby certify that the record provided above is correct to the best of my knowledge and that all of the mileage for which I am requesting
reimbursement is related to or is for treatment authorized under Nevada Revised Statute (NRS) 616A to 616D, inclusive or chapter 617 of
NRS. I understand that the reporting of false information may disqualify me from receiving workers’ compensation benefits, and
may subject me to criminal and civil penalties. I certify under penalty of perjury that the above information is correct to the best of my
knowledge.
__________________________________________________
_________________________________
Injured Employee’s Signature
Date
D-26(1)
(Rev. 4/04)
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