Travel Reimbursement Form

Claim Number NWRTP230099601

Date of Accident 30 March 2023
Injured Person Polina Vlasova

You can seek reimbursement for travel expenses related to attending approved treatment, rehabilitation
services, consultations with doctors or an independent health service provider examination.

Return Kilometres
Date From To Reason per trip
(Circle)

15/01/2020 Address Address Dr Example Y/N 15

27/07/2023 12 Audrey Ave Vincentia Bay Medical Doctor Y 44

Basin View

03/07/2023 12 Audrey Ave Vincentia Bay Medical Doctor Y 44

Basin View

06/07/2023 12 Audrey Ave Vincentia Bay Medical Doctor Y 44

Basin View

07/07/2023 12 Audrey Ave Vincentia Bay Medical Mental health Y 44

Basin View

13/07/2023 12 Audrey Ave 48 Collden Ave Physio Y 52

Basin View Vincentia

25/07/2023 12 Audrey Ave Vincentia Bay Medical Doctor Y 44

Basin View

03/08/2023 12 Audrey Ave Vincentia Bay Medical Doctor Y 44

Basin View

Total kilometres travelled

316

Name

Polina Vlasova
Signature Date (dd/mm/yyyy)

04/08/2023

Please send completed form by email to injuryclaims@iag.com.au, fax to 0290889696 or post to NRMA
Insurance CTP Claims Reply Paid 481 Sydney NSW 2001.

Insurance Australia Limited ABN 11 000 016 722 AFSL 227681 trading as NRMA Insurance nrma.com.au Page 1 of 1