Free - Nevada

REQUEST FOR REIMBURSEMENT OF EXPENSES FOR TRAVEL AND LOST WAGES
Pursuant to NRS 616C.365 and 616C.477

Claim No: Date of Injury: Insurer's Name: Injured Employee's Name: Present Employer: Date of Hearing/Treatment: Time of Hearing/Treatment: Begin From: Place of Employment Residence* End (Check One)
*DO NOT USE RESIDENCE FOR EXTENDED TRAVEL BENEFIT

Social Security No. Phone No:

Address: To: Place of Hearing/Treatment: Address: FOR TRAVEL AND LOST WAGES FOR HEARINGS Pursuant to NRS 616C.365 FOR INSURER'S USE Total Miles Traveled (One Way) . . .. Food . . . . . . . . . . . . . . . . . . . . . . . . . . Lodging . . . . . . . . . . . . . . . . . . . . . Lost Wages . . . . . . . . . . . . . . . . . . . . . Total Expenses . . . . . . . . . . . . . . . . ..
Miles X 2 X per mile =

Total $

LOST WAGES COMPENSATION FOR EXTENDED MEDICAL TRAVEL Pursuant to NRS 616C.477 Employer at time of injury: FOR INSURER'S USE Total Miles Traveled (One Way) . . . . . . .. Total Time Absent from Employment . . ..
Qualify? TTD YES or 50% or NO 100 %

TTD RATE $ I declare under penalty of perjury that the above amounts were necessarily incurred and that they are true and correct to the best of my knowledge.

Date

Signature of Injured Employee

D-24 (rev. 6/2006)