[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-307243-105":53,"doc-detail-307243-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","ia-mileage-form-mileage-expense-reimbursement","I&A mileage form - Mileage expense reimbursement","","Mileage expense reimbursement form for injured workers to claim travel costs when obtaining treatment for a work injury. The form states the mileage rate of 76 cents ($0.76) per mile and that reasonable travel including pharmacy visits, parking, bridge tolls, public transportation, and related expenses are covered. It instructs claimants to complete the form, attach receipts, send the original to the insurance company, keep a copy, and not submit to the local WCAB or assistance officer.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/ia-mileage-form-mileage-expense-reimbursement/307243/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/ia-mileage-form-mileage-expense-reimbursement/307243.png","ImageObject",442,249,{"name":88,"@type":89},"Stanley","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-27","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What mileage rate does the form use?","Question",{"text":108,"@type":109},"The form sets the mileage rate at 76 cents ($0.76) per mile.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which travel-related expenses are included?",{"text":113,"@type":109},"Reasonable travel costs are included, such as trips to the pharmacy, parking, bridge tolls, public transportation, and other related travel expenses.",{"name":115,"@type":106,"acceptedAnswer":116},"Where should the completed form and receipts be sent?",{"text":117,"@type":109},"Complete the form and attach receipts, then send the original to the insurance company and keep a copy.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},307243,1790157774,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},2336477405376,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Injured worker’s name / Claim number / Número de reclamo  \nNombre de la persona lesionada  \nMedical mileage expense form Formulario de gastos de viajes para asuntos médicos  \nIf you have to travel to get treatment for your work injury, you are entitled to re-payment of your travel costs. The mileage rate is 76 cents ($0 . 76) per mile. Mileage for reasonable travel to the pharmacy, parking, bridge tolls, public transportation and other travel-related costs are also included. Complete this form. Attach receipts. Send the original to the insurance company and keep a copy. Do not send the original or a copy to the local Workers’Compensation Appeals Board (WCAB) or the information and assistance officer. If your travel costs are not paid within 60 days, contact the information and assistance officer.  \nSi tiene que viajar para recibir tratamiento por una lesión en el trabajo, usted tiene derecho a recibir un reembolso de 76 centavos ($0.76 por milla. Millas por un viaje de distancia razonable a la farmacia, estacionamiento, pago de peajes, transporte público y otros viajes y costos relacionados están también incluidos. Complete este formulario y adjunte los recibos. Envíe la forma original a la compañía de seguros y guarde una copia. No envíe el original o la copia a la oficina local de la Junta de Apelaciones de Compensación del Trabajador (WCAB) . Si sus gastos de viajes no son pagados dentro de 60 días, llame al representante de información y asistencia.  \n\n| Date/\u003Cbr>Fecha | Traveled from\u003Cbr>(include address)\u003Cbr>Viajó desde\u003Cbr>(incluya dirección) | Traveled to (include name and address of doctor, hospital, therapist, etc.)\u003Cbr>Viajó a (incluya nombre y direccióndel médico, hospital, terapeuta, etc. ) | Round trip mileage/\u003Cbr>Millas del viaje entero | Parking/\u003Cbr>Estacionamiento | Tolls/\u003Cbr>Peajes |\n| --- | --- | --- | --- | --- | --- |\n| Sample: 07/01/26 | Sample: 1515 Maple, San Francisco | Sample: Dr. Sherman, 190 Oak, San Francisco | Sample:\u003Cbr>14 mi | Sample:$2.50 | Sample:$ |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n| California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to finesand confinement in state prison. |  | Total miles / Número de millas viajadas en total | 0 | x $0.76 / mile = | $ 0.00 |\n|  |  |  |  | Total parking/Estacionamiento pagado en total | $ 0.00 |\n|  |  |  |  | Total tolls/Peajes\u003Cbr>pagados en total | $ 0.00 |\n|  |  |  |  |  |  |\n|  |  |  | Total reimbursement requested/ Reembolso\u003Cbr>solicitado en total |  | $ 0.00 |\n| Las Leyes de California establecen que lasiguiente declaración aparezca en este formulario: Cualquier persona que asabiendas presente reclamos falsos ofraudulentos para el pago de una pérdida, es culpable de un delito y podría ser sujeto a multas y encarcelamiento en una prisión estatal. |  | Signature / Firma |  |  |  |\n|  |  | Printed name / Imprima su nombre |  |  |  |\n|  |  | Date / Fecha |  |  |  |\n\nI&A mileage form (for mileage after 07/01/2026) Rev. 7/26","cbCaih5jzEjzT5at","https://ap.wps.com/l/cbCaih5jzEjzT5at","pdf",869124,"English","# Claimant and claim details\n# Travel information\n## Travel origin and destination\n## Mileage, parking, and tolls\n# Submission instructions\n# Totals and certification","[{\"question\":\"What mileage rate does the form use?\",\"answer\":\"The form sets the mileage rate at 76 cents ($0.76) per mile.\"},{\"question\":\"Which travel-related expenses are included?\",\"answer\":\"Reasonable travel costs are included, such as trips to the pharmacy, parking, bridge tolls, public transportation, and other related travel expenses.\"},{\"question\":\"Where should the completed form and receipts be sent?\",\"answer\":\"Complete the form and attach receipts, then send the original to the insurance company and keep a copy.\"}]","I&A mileage form - Mileage expense reimbursement | PDF",1789846195]