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___ Employer:_____________________ List trip(s) taken such as home to doctor, home to hospital, identify doctor, pharmacy, hospital by name and address and return home Beginning Location Address Ending Location Address Round Trip Mileage Total Mileage Please complete and mail to: LUBA Workers’ Comp PO Box 98082 Baton Rouge, LA 70898-9082 I certify that the above information furnished by me is true and correct and based on such information hereby claim payment for the mileage indicated. S.

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