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Mileage Reimbursement - Mileage Reimbursement

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Workers Compensation
Mileage Reimbursement
Name:
Address:
Zip Code
Social Security #:
(Required)
Submit your mileage for all trips that exceed 5 miles round trip, if the purpose of the trip was
to obtain medical care or purchase medically related items, such as prescriptions. Please
submit this mileage request on a monthly basis until your file is closed.
Date Miles Destination
Mail to: State Self Insurance Fund
900 SW Jackson, Room 951-S
Landon State Office Building
Topeka KS 66612-1251
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Mileage Reimbursement - Mileage Reimbursement

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Completed 12 March 2020

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