FORM 25T

North Carolina Industrial Commission
Itemized statement of charges for travel

The use of this form is required under the provisions of the Workers' Compensation Act

Incident Report Identifiers:
IC File #
*Emp. Code #
*Carrier Code #
Employer FEIN
Carrier File #

* Required Information

 

Employee Information:

   
Employee's Name    
Address    
City State Zip
Home Telephone Work Telephone
M F
Social Security Number Sex Date of Birth

Employer Information:

Employer's Name Telephone Number
Employer's Address City State Zip

Insurance Carrier Information:

Insurance Carrier Policy Number
Carrier's Address City State Zip
Carrier's Telephone Number Fax Number

Medical Provider Information

Date
Name of Medical Provider
City
Total Miles Roundtrip
OTHER
EXPENSES		 If overnight stay is necessary, the following items will be approved as submitted. (Receipts must be furnished for carrier's file)
Total motel expense ($45.00 per day):

Total Miles:
Total meal expense ($6.00 Breakfast, $8.00 Lunch, and $14.00 Dinner):
X [mileage rate]* equals:
Total parking & cab expense
(actual charge):

Other expenses:
Total for other expenses:
Total all expenses:

*The mileage rate is $0.555 for travel, starting July 1, 2011; $0.51 for January 1-June 30, 2011;
$0.50 for 2010; $0.55 for 2009; $0.585 for July 1 to December 31, 2008; $0.505 for January 1 to
June 30, 2008; $0.485 for 2007; $0.445 for January 18 to December 31, 2006; and $0.31 for travel
before that date.


I hereby certify that I have incurred all expenses listed above as a result of my workers' compensation injury.

________________________________________
________________________________________
Employee Signature
Carrier's Approval
     
Employee:   Employer or Carrier / Administrator:
Mail your bill in duplicate promptly to employer
and / or insurance carrier 		  Travel may be reimbursed directly to the employee. It is not necessary to submit bills to the Commission for approval. Pay and retain copy in carrier's file.

Form 25T
07/11
Page 1 of 1
Form 25T
For Assistance, Call:
N.C. Industrial Commission
Main Telephone: (919) 807-2500
Workers' Compensation Information
Specialists: (800) 688-8349