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Get Accident Fund Travel Reimbursement Form

State Accident Fund Mileage Reimbursement Form Injured Worker Name clmt Home Address addr Employer employer Claim No cno Date of Accident doi Mileage must be more than 10 miles round trip Mileage will not be paid for travel to the drug store Rate 01/01/01 - 06/30/06. 345 07/01/06 - 06/30/08. 445 07/01/08 - 12/31/09. 505 01/01/10 12/31/10. 50 01/01/11 06/30/2012. 505 07/01/2012 12/31/2012. 555 01/01/2013 12/31/2103. 565 01/01/2014 12/31/2014.

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