TRAVEL ARRANGEMENTS FOR CLAIMANT

Today’s Date: ________________ Completed by: _____________________________

Claimant Name: ________________________________ File #:___________________

Appointment Date: ________________ Type: ____________ Doctor: ______________

Flight Arrangements Required? ___________ # of Flight(s) Booked? ______________

Flight Provider: ______________________ Total Cost of Flight(s): ________________

Inbound Flight #: _______________________ Outbound Flight #: _________________

E Ticket Received? ________________ E Ticket Sent to Claimant? _______________

Taxi Arrangements Required?___________ # of Taxi(s) Booked? _________________

Hotel Arrangements Required? ____________ # of rooms Booked? _______________

Hotel Name: __________________________ Total Cost of Room(s): ______________

Additional Accommodation Details:

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