Fill and Sign the Contact Us About Third Party Claim Cost Recovery Lampampi Form

F245-375-000 Plan Transportation Cost Encumbrance 09-2015 Index: VPLAN Department of Labor and Industries Claims Section PO Box 44269 Olympia WA 98504-4269 Plan Transportation Cost Encumbrance Original Revised Modified Early Termination This form contains auto calculations Date Worker Name Claim # Worker Address ( Trip start )       Vendor Section A B C D Vendor Provider # Vendor Name Billing Codes A B C D Parking 0302R $ 0.00 Bridge/Ferry Tolls 0303R $ 0.00 Commercial Transportation 0304R $ 0.00 Cost Subtotal $ 0.00 $ 0.00 $ 0.00 $ 0.00 From       From From From Dates of Service To To To To $0.00 Cost Total Mileage Calculation 0301R A B C D Training Site Address, City, State (Trip end) # of round trip miles for most direct route; round to next highest mile. # of training days Costs in this section will be totaled by L&I Vocational Provider Assigned VRC Name Signature Firm Provider # Branch # VRC # VRC Phone # VRC Fax # Department Use Only VSS Signature Date      Approved Not Approved