Form 2721A Worker Health Care Travel Expense Form - Ontario, Canada

WSIB Travel Expense Form Instructions

Here is how you should fill out WSIB Travel Expense Form:

1. State the number of your claim - before you can submit this form, you need to prepare a claim and file it with the human resources department so that the expenses are pre-approved and the payment is not delayed.
2. Write down your full name, current address, and telephone numbers. If you have a new address, check the appropriate box.
3. Describe your travels - date and time, points of departure and arrival, and the reason for travel. Obtain the stamp of the treating agency or the name and signature of your physician. Indicate whether you traveled by public transit or taxi and record the amount of money you have spent.
4. Enter the roundtrip distance and the sum of money you spent on parking if necessary. Provide a full breakdown of meal expenses.
5. Calculate the total amount of expenses and write it down at the bottom of the form.
6. Confirm the details in the document are true and complete, enter your full name, sign and date the form. Note that the statement alone is not enough - you need to attach original parking receipts, taxi receipts, and other documentation that proves you have spent the amount of money stated in the form.

Complete this document during the travel to keep track of all the payments and expenses and then mail it to 200 Front St W Toronto, Ontario, M5V 3J1. Keep a copy of the form for your own records.