Get Form 25t

Filling out the Form 25t is an important step in the process of seeking reimbursement for travel expenses related to medical treatment under the Workers' Compensation Act. This guide provides a clear, step-by-step approach to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the Form 25t online.

1. Click the ‘Get Form’ button to obtain the form and access it in the online editor.
2. In the first section, enter your employee code, carrier code, and carrier file number as required. These numbers are essential for identifying your claim.
3. Fill in your employer's Federal Employer Identification Number (FEIN) along with the employer's name and address details. Make sure to provide accurate information to avoid processing delays.
4. Next, complete the section for the employee's name, home telephone number, and residential address, including city, state, and zip code.
5. In the insurance carrier section, input the carrier's address, city, state, zip, and telephone number. Ensure this information is detailed and exact.
6. Document your travel details, beginning with the date of travel and the name of the medical provider. Additionally, complete the total miles traveled roundtrip.
7. Fill in any other expenses incurred, such as total motel expenses, meal expenses, and any parking or cab charges. Ensure you keep receipts for these expenses.
8. Calculate the total of all expenses and enter this at the bottom of the expense section. Ensure that all calculations are accurate for proper reimbursement.
9. Sign the form to certify that you have incurred all listed expenses due to your workers' compensation injury.
10. Once you have completed the form, save your changes, and use the download feature to save a copy. You may also print or share the filled form if needed.

Start completing your forms online to ensure timely processing of your expenses.