Form - Travel and Expense Reimbursement

Travel Expense Reimbursement

Sedgwick Pooling Services – General travel and reimbursement requests for self-insured pool member representatives only. This is not a mileage form for claimants. Reimbursement requests related to a claim should be submitted directly to the claim adjuster or examiner.

Date of Request
MM slash DD slash YYYY
Name*
Entity Name
Pool or JPA Affiliation
Phone
Email*
Check payable to:
Reason for travel or expense:
Travel location
Start Date of Event
MM slash DD slash YYYY
Cost of Airfare
Auto Mileage Costs (total miles multiplied by the current IRS standard mileage rate at 67.0 cents):
Parking fee(s) amount:
Toll fare(s) amount:
Other transportation cost(s) amount:
Meal(s) amount:
Lodging amount:
Other travel related cost(s) amount:
Total Amount of Reimbursement Request:
File Upload
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Max. file size: 50 MB.
Attach itemized receipts or other documents supporting the reimbursement request.

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Request Travel and Expense Reimbursement

Travel Expense Reimbursement