g:\admin\workers comp\forms\wc mileage reimbursement form 2023.docx Reviewed August 2023
Workers’ Compensation
Mileage Reimbursement Requests
In some cases, Broadspire, OSU’s third-party workers’ compensation
administrator, may reimburse expenses such as mileage incurred while
seeking treatment for workers’ compensation claims. An injured worker
may submit the following document to Broadspire for review in
coordination with the claim. Please note that employees who have hired
an attorney to assist them with their workers’ compensation claim must
submit their requests for mileage reimbursement through their attorney.
If you believe you are owed mileage for your claim, please submit the attached document directly to Broadspire
via fax at (859) 550-2175 or email to [email protected] or mail the form to Broadspire
Claims, PO Box 14342, Lexington, KY 40512-4342.
WORKERS' COMPENSATION MILEAGE CLAIM
Name: Claim Number:
Date of Injury: Phone Number:
Home Address:
City, State, Zip:
TRAVEL
DATE
NAME AND ADDRESS OF DOCTOR/HOSPITAL OR PHARMACY
ROUND TRIP
MILEAGE
TOTAL
I certify that the above information furnished by me is true and correct, and based on such information, I hereby file this claim to pay for
the mileage as indicated.
University Human
Resources
Date
Signature
