Get Ca I&a Mileage Form 2013

Filling out the CA I&A Mileage Form is an essential step for individuals who need to claim reimbursement for travel expenses related to medical treatment for work injuries. This guide will walk you through each section of the form, ensuring you complete it accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the CA I&A Mileage Form and open it in your editor.
2. Enter the injured worker's name and claim number in the designated fields at the top of the form.
3. Fill in the date of travel and the address you traveled from. Be sure to provide complete information.
4. Next, specify the destination by including the name and address of the medical provider (doctor, hospital, therapist, etc.) you visited.
5. Indicate the total miles traveled for the round trip. Make sure to calculate the total distance accurately.
6. Enter any parking fees incurred during your travel in the parking section, along with the amount for tolls in the indicated tolls section of the form.
7. Calculate the total reimbursement requested by adding the mileage reimbursement to any parking and toll expenses. Use the mileage rate of $0.545 per mile for the calculation.
8. Sign the form at the bottom and print your name clearly in the designated field.
9. Once you have filled out all necessary fields and double-checked your entries, save the changes to your document.
10. You can now download, print, or share your completed form as needed. Remember to send the original to the insurance company and keep a copy for your records.

Start completing your CA I&A Mileage Form online today!