How to Complete the Workers' Compensation Mileage Reimbursement Form in California

What Is a Workers' Compensation Mileage Reimbursement Form?

The mileage reimbursement form is a statutory document used in California to claim travel expenses incurred while performing job‑related duties for a workers' compensation claim. It ensures that injured workers receive the IRS‑approved rate (currently $0.65 per mile) for trips to medical appointments, therapy sessions, or employer‑requested travel.

When Is Mileage Reimbursement Required?

Under California Labor Code 460 and the California Workers' Compensation Insurance Rating Bureau (WCIRB) guidelines, an employer or insurer must reimburse reasonable travel costs when:

• The employee is injured or ill on the job.
• The travel is directly related to medical treatment, evaluation, or claim administration.
• The employee does not have a personal vehicle provided by the employer for the trip.

Key Elements of the California Form

The standard form (WC‑IRB Form 101) includes the following fields. Fill each accurately to avoid delays:

• Employee Information: name, claim number, Social Security number (last four digits only), and contact details.
• Employer/Insurer Information: name, address, and WCIRB claim administrator.
• Trip Details: date of travel, purpose (e.g., "Medical appointment – orthopedist"), start and end locations, and total miles driven.
• Rate Applied: the statutory mileage rate ($0.65 per mile as of 2024).
• Total Reimbursement Amount: calculated mileage multiplied by the rate.
• Certification: employee signature, date, and a statement that the mileage is accurate and not previously reimbursed.

Step‑by‑Step Completion Guide

1. Gather Supporting Documents

Collect appointment letters, doctor's notes, or a calendar entry that confirms the date, time, and purpose of each trip. Keep a mileage log (odometer start/end readings or a trusted app) for verification.

2. Fill In Employee and Claim Information

Enter your full legal name, claim number (found on your workers' comp benefits statement), and the last four digits of your SSN. This links the reimbursement to the correct claim.

3. Document Each Trip

For every travel event, list:

• Exact date (MM/DD/YYYY).
• Purpose (e.g., "Follow‑up physical therapy").
• Starting address and destination address.
• Total miles (use your log or an online mileage calculator).

4. Apply the Current Rate

Multiply the total miles by $0.65. Example: 45 miles × $0.65 = $29.25.

5. Calculate the Grand Total

If you have multiple trips on the same form, sum each line's reimbursement amount and enter the total in the final field.

6. Sign and Date

Read the certification statement carefully, sign, and date the form. Your signature confirms the mileage is accurate and not previously claimed.

Submitting the Form

Submit the completed form to one of the following recipients, depending on your claim's handling:

• Employer's HR/Payroll Department – if they process workers' comp reimbursements directly.
• Claims Administrator or Insurance Carrier – use the address on your benefits statement.
• California Department of Industrial Relations (DIR) – only if your employer refuses to reimburse and you need to file a formal complaint.

Include copies of all supporting documents. Retain the original for your records.

Common Mistakes to Avoid

• Using the Wrong Rate: The rate is set by the California Department of Tax and Fee Administration and changes infrequently. Verify the current rate before calculating.
• Missing Trip Purpose: Vague descriptions (e.g., "travel") can be rejected. Be specific about the medical provider and appointment type.
• Double‑Counting Miles: Only claim mileage for the round‑trip distance, not the cumulative total of multiple unrelated trips on the same day.
• Failing to Attach Proof: Without appointment letters or a mileage log, the insurer may request additional evidence, delaying payment.

Typical Reimbursement Timeline

FAQs

Q: Can I claim mileage for rideshare or public transit?A: Only personal vehicle mileage is reimbursable at the statutory rate. Public‑transit fares are reimbursed separately under a different expense category.

Q: What if my employer uses a different mileage rate?A: California law requires the $0.65 rate for workers' comp claims. Employers cannot apply a lower rate, though they may choose to pay a higher amount voluntarily.

Q: Do I need a separate form for each claim?A: Yes. Each workers' comp claim (identified by its claim number) requires its own mileage reimbursement form.

Q: How far back can I submit mileage?A: Most insurers accept claims for travel incurred within the past 12 months, provided you have adequate documentation.