Get Po Box 3151 Charleston Wv 25332

Filling out the travel voucher for BrickStreet Insurance is an essential step for claiming reimbursement for eligible travel-related expenses. This guide will provide you with clear instructions to ensure a smooth online submission process.

Follow the steps to fill out the travel voucher form accurately.

1. Use the ‘Get Form’ button to access the travel voucher form and display it in your online editing tool.
2. Enter the claimant’s name, including your first, middle, and last name, as it appears in official correspondence.
3. Provide your complete mailing address. Ensure to include street, city, state, and zip code.
4. Input your Social Security number in the designated field.
5. Record the date of your injury. For occupational pneumoconiosis claims, this refers to the date of last exposure.
6. Fill in your unique claim number assigned to your case by BrickStreet Insurance.
7. Write the name of the service provider you visited for your medical needs.
8. Enter the authorization number if applicable. This number is necessary for services requiring prior approval.
9. Provide the complete address of your point of departure. Ensure you include your physical street address.
10. Fill in the complete address of your point of destination, which is the address of the service provider's office.
11. Indicate the time you departed from your residence.
12. Record the time you returned to your residence.
13. Clearly describe the purpose of your travel.
14. Include the date of travel, along with separate entries for meals, lodging, or other expenses.
15. Input the appropriate travel procedure code for each type of expense being claimed.
16. Provide a description of each expense, specifying what it was for.
17. Enter the quantity of units traveled, typically measured in miles.
18. Record the total charges for each line item.
19. Make sure that the service provider signs the form for verification.
20. Sign and date the form as the claimant to confirm its accuracy.
21. Calculate and state the total charges for all items listed in the charges column.
22. If applicable, fill out the sections for employer details, lost wages will be handled by them.
23. Once completed, save the form and any necessary receipts. Ensure copies are made for your records before submitting it to BrickStreet Insurance.

Submit your travel voucher online today to begin your reimbursement process.