North Carolina Workers' Comp Travel Reimbursement Form
This form is used by employees in North Carolina to claim travel expense reimbursement under the Workers' Compensation Act. It covers expenses such as mileage, meals, and lodging. The form must be submitted to the employer or insurance carrier for approval.
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How do I fill this out?
To fill out this form, start by providing your personal and employer information. Next, itemize all travel expenses incurred in relation to your workers' compensation claim. Finally, sign and submit the form to your employer or insurance carrier.
How to fill out the North Carolina Workers' Comp Travel Reimbursement Form?
1
Provide your personal and employer information.
2
Itemize all travel expenses incurred.
3
Total the expenses.
4
Sign the form.
5
Submit the form to your employer or insurance carrier.
Who needs the North Carolina Workers' Comp Travel Reimbursement Form?
1
Employees injured on the job who need to claim travel expenses under workers' compensation.
2
Employers who need to process and approve travel reimbursement claims.
3
Insurance carriers responsible for workers' compensation claims.
4
Human resources departments managing employee claims.
5
Legal professionals handling workers' compensation cases.
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What are the instructions for submitting this form?
Complete the form with accurate employee and travel expense information. Submit the form to your employer or insurance carrier. The submission can be done through email, fax, or physical mail. Ensure all required fields and signatures are completed before submission. For additional assistance, contact the N.C. Industrial Commission at (919) 807-2500 or the helpline at (800) 688-8349.
What are the important dates for this form in 2024 and 2025?
For travel beginning January 1, 2024, and onwards, the mileage reimbursement rate is $0.67 per mile. Meal and lodging reimbursement rates are updated as of July 1, 2023.
What is the purpose of this form?
The primary purpose of this form is to allow employees in North Carolina to itemize and claim travel expenses incurred due to a workers' compensation injury. The form ensures that employees are fairly reimbursed for necessary travel, meals, and lodging while seeking medical care or other related services. Employers and insurance carriers use the form to process and approve reimbursement claims, maintaining proper documentation for workers' compensation cases.
Tell me about this form and its components and fields line-by-line.
- 1. Employee's Name: The full name of the employee seeking reimbursement.
- 2. Employee's Address: The home address of the employee including city, state, and zip code.
- 3. Home Telephone: The employee's home telephone number.
- 4. Employer's Name: The name of the employer where the employee works.
- 5. Employer's Address: The address of the employer including city, state, and zip code.
- 6. Work Telephone: The employer's work telephone number.
- 7. Insurance Carrier: The name and contact information of the insurance carrier handling the claim.
- 8. Travel Expenses: Itemized list of travel expenses including date, destination, and total miles roundtrip.
- 9. Total Reimbursement: The total amount being claimed for reimbursement, including mileage, meals, lodging, and other expenses.
- 10. Employee Signature: The signature of the employee certifying that the expenses were incurred due to the workers' compensation injury.
- 11. Carrier's Approval: The approval signature from the insurance carrier or employer representative.
What happens if I fail to submit this form?
Failure to submit this form can lead to delays or denial of travel expense reimbursement under the workers' compensation claim.
- Delayed Reimbursement: Submission delays can result in late reimbursement for incurred expenses.
- Claim Denial: Without submission, the claim for reimbursement may be denied entirely, affecting the employee's ability to recover expenses.
How do I know when to use this form?
- 1. Medical Visits: Used for travel expenses incurred when visiting healthcare providers for workers' compensation-related treatment.
- 2. Physical Therapy: Used for travel expenses related to physical therapy sessions needed for recovery.
- 3. Rehabilitation: Used for travel expenses linked to rehabilitation services following an injury.
- 4. Legal Appointments: Used for travel expenses when attending legal appointments related to the workers' compensation claim.
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What types of expenses can be claimed with this form?
You can claim travel expenses related to your workers' compensation claim, such as mileage, meals, and lodging.
Who needs to approve the form?
The form needs to be approved by your employer or insurance carrier.
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