CLAIM FOR TRAVEL EXPENSES
This form is used to claim your travel expenses when travelling to and from medical treatment or a medical appointment arranged
by CGU Workers Compensation.
You are entitled $0.55 per kilometre or the amount of your public transport fare.
You must attach all original receipts.
Name
Date of injury
D D / MM / Y Y
Address
Claim number
Suburb
State
Postcode
Date of
appointment
Appointment with
Travel from
Travel to
Kilometres
travelled
(travel by
car only)
Amount
claimed
Yes / No
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
D D / MM / Y Y
km
$
km
$
Total
Original
receipts
attached
Please note: As per section 60(2A) and (2B) of the Workers Compensation Act 1987:
• Travel expenses will not be paid unless prior approval has been sought and granted by CGU for the
treatment or service you are claiming travel reimbursement to.
• Travel expenses are not payable if you have travelled further than is reasonably necessary to obtain
the treatment or service.
Please return this completed form to CGU Workers Compensation (NSW) Limited at the below address.
Ph: 1300 666 506
GPO Box 9960, Sydney NSW 2001
[email protected]
WOR0774 REV4 5/15
CGU Workers Compensation (NSW) Limited
Agent for the NSW WorkCover Scheme
ABN 83 564 379 108/007