Form 2721A "Worker Health Care Travel Expense Form" - Ontario, Canada

What Is Form 2721A?

Form 2721A, Worker Travel Expense Form, is a document Ontario-based employees prepare before they travel to treat their workplace injuries and illnesses to be reimbursed for incurred expenses. The Workplace Safety and Insurance Board (WSIB) guarantees they will pay for your travel expenses after it will be confirmed you actually had a medical appointment as a result of the workplace-related injury or illness.

Alternate Name:

  • WSIB Travel Expense Form.

The latest version of the document was released on December 1, 2013, with all previous editions obsolete. You can download a fillable WSIB Travel Expense Form via the link below.

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WSIB Travel Expense Form Instructions

Here is how you should fill out WSIB Travel Expense Form:

  1. State the number of your claim - before you can submit this form, you need to prepare a claim and file it with the human resources department so that the expenses are pre-approved and the payment is not delayed.
  2. Write down your full name, current address, and telephone numbers. If you have a new address, check the appropriate box.
  3. Describe your travels - date and time, points of departure and arrival, and the reason for travel. Obtain the stamp of the treating agency or the name and signature of your physician. Indicate whether you traveled by public transit or taxi and record the amount of money you have spent.
  4. Enter the roundtrip distance and the sum of money you spent on parking if necessary. Provide a full breakdown of meal expenses.
  5. Calculate the total amount of expenses and write it down at the bottom of the form.
  6. Confirm the details in the document are true and complete, enter your full name, sign and date the form. Note that the statement alone is not enough - you need to attach original parking receipts, taxi receipts, and other documentation that proves you have spent the amount of money stated in the form.

Complete this document during the travel to keep track of all the payments and expenses and then mail it to 200 Front St W Toronto, Ontario, M5V 3J1. Keep a copy of the form for your own records.

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Download Form 2721A "Worker Health Care Travel Expense Form" - Ontario, Canada

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INSTRUCTION SHEET
Worker Travel Expense Form
General Information and Instructions:
pre-approved
Travel expenses for medical appointments for your workplace injury/illness must be
to avoid delays in payment.
The Worker Travel Expense Form (2721A) should be completed based on the travel expenses approved in your claim. Please
contact the WSIB at 416-344-1000 or 1-800-387-0750 to find out what expenses you may claim. You should also advise the
WSIB whenever there is a change in the travel needs for your injury/illness (i.e. when you are referred to a new doctor or
treatment program).
NOTE: If you are awaiting a decision on your claim, you can use this form to record your travel expenses.
Please submit the form to the WSIB only after your injury or illness is accepted as being work-related.
In general, we pay only the cost of public transit fares to medical appointments, when public transportation is available in your
area and your injury/illness does not prevent you from using public transit.
Mileage (and parking) is paid only when there is no public transit, or the medical evidence on file shows you can not take public
transit because of your injury/illness. If the WSIB has approved mileage, and you also have parking expenses, use the same
send in the original parking receipt(s)
form and
.
Travel by taxi is approved only when medical evidence indicates your injury/illness prevents you from taking public transit or
driving your own vehicle.
If you tell us in advance of the appointment, we will arrange for the taxi company to bill the WSIB directly,
wherever possible.
send in the original taxi receipt(s)
When you have paid the taxi fare, you must
with your claim form.
Generally, we consider eligibility for meals only when your appointment involves out-of-town travel. You will not be
reimbursed for your meal(s) unless you were advised to claim for it. There are different maximum limits paid for each of the
three daily meals.
must be pre-approved.
If you need an escort when travelling, for medical or legal reasons, escort fees can be paid but
There are set fees for an escort. If you have entitlement for an escort and a meal(s), we will also pay for your escort’s meal(s).
You will need to attach a separate sheet to claim the escort fee and any additional expenses for your escort.
Confirming attendance is important:
Travel expenses are paid after we confirm that you attended a medical appointment for your workplace injury/illness on that
date. We do this by checking if we have paid for the treatment, such as physiotherapy, or have a report from the doctor you saw.
Since we do not always receive an invoice or report, you should take a travel form to all your appointments and have the
treating agency or doctor put their stamp, or name and signature, beside the date of your appointment.
Details are important for quick payment as incomplete forms cannot be processed. Please check the
following before mailing your form
Is your name and claim number on each form and receipt?
Did you provide all the information asked for?
Did you do all of the calculations for the amounts you are claiming?
Did you attach all original parking or taxi receipts, if applicable?
signed
dated
Is the form
and
?
Keeping your own records:
We recommend you keep a copy of the completed form and all receipts for your own records. This allows you to keep track of your
expense claims and payments. This also prevents you from making a duplicate claim for an expense already claimed and/or paid,
which will cause a delay.
www.wsib.on.ca
This website –
– has more information about travel expenses. By using the search field and typing in Table of
Rates, you will find the current rates and other related policies.
2721A (12/13)
www.wsib.on.ca
INSTRUCTION SHEET
Worker Travel Expense Form
General Information and Instructions:
pre-approved
Travel expenses for medical appointments for your workplace injury/illness must be
to avoid delays in payment.
The Worker Travel Expense Form (2721A) should be completed based on the travel expenses approved in your claim. Please
contact the WSIB at 416-344-1000 or 1-800-387-0750 to find out what expenses you may claim. You should also advise the
WSIB whenever there is a change in the travel needs for your injury/illness (i.e. when you are referred to a new doctor or
treatment program).
NOTE: If you are awaiting a decision on your claim, you can use this form to record your travel expenses.
Please submit the form to the WSIB only after your injury or illness is accepted as being work-related.
In general, we pay only the cost of public transit fares to medical appointments, when public transportation is available in your
area and your injury/illness does not prevent you from using public transit.
Mileage (and parking) is paid only when there is no public transit, or the medical evidence on file shows you can not take public
transit because of your injury/illness. If the WSIB has approved mileage, and you also have parking expenses, use the same
send in the original parking receipt(s)
form and
.
Travel by taxi is approved only when medical evidence indicates your injury/illness prevents you from taking public transit or
driving your own vehicle.
If you tell us in advance of the appointment, we will arrange for the taxi company to bill the WSIB directly,
wherever possible.
send in the original taxi receipt(s)
When you have paid the taxi fare, you must
with your claim form.
Generally, we consider eligibility for meals only when your appointment involves out-of-town travel. You will not be
reimbursed for your meal(s) unless you were advised to claim for it. There are different maximum limits paid for each of the
three daily meals.
must be pre-approved.
If you need an escort when travelling, for medical or legal reasons, escort fees can be paid but
There are set fees for an escort. If you have entitlement for an escort and a meal(s), we will also pay for your escort’s meal(s).
You will need to attach a separate sheet to claim the escort fee and any additional expenses for your escort.
Confirming attendance is important:
Travel expenses are paid after we confirm that you attended a medical appointment for your workplace injury/illness on that
date. We do this by checking if we have paid for the treatment, such as physiotherapy, or have a report from the doctor you saw.
Since we do not always receive an invoice or report, you should take a travel form to all your appointments and have the
treating agency or doctor put their stamp, or name and signature, beside the date of your appointment.
Details are important for quick payment as incomplete forms cannot be processed. Please check the
following before mailing your form
Is your name and claim number on each form and receipt?
Did you provide all the information asked for?
Did you do all of the calculations for the amounts you are claiming?
Did you attach all original parking or taxi receipts, if applicable?
signed
dated
Is the form
and
?
Keeping your own records:
We recommend you keep a copy of the completed form and all receipts for your own records. This allows you to keep track of your
expense claims and payments. This also prevents you from making a duplicate claim for an expense already claimed and/or paid,
which will cause a delay.
www.wsib.on.ca
This website –
– has more information about travel expenses. By using the search field and typing in Table of
Rates, you will find the current rates and other related policies.
2721A (12/13)
www.wsib.on.ca
Worker Health Care
Mail To:
OR FaxTo:
Travel Expense Form
200 Front Street West
416-344-4684
Toronto ON M5V 3J1
OR 1-888-313-7373
Claim Number (mandatory)
Please PRINT in black ink.
BEFORE completing this form,
Start >
please read the INSTRUCTIONS.
A. Worker Information
Last name
First name
Initial
City
Current address
Province
Postal Code
ON
Is this a new address?
Home phone
Work phone
yes
no
B. Travel Expense Section
Please provide all information requested and complete ALL calculations.
Driving
Meals Amount
Public Transit
Roundtrip
Breakfast $
Treating Agency Stamp or
B-
Parking
Travel Address
or Taxi
Distance in Km
Lunch $
Name & Signature
L-
Amount ($)
Amount ($)
(kilometers)
Dinner $
D-
Date
Public
B - $
Taxi
(dd/mm/yyyy)
Transit
AM
PM
Time:
$
$
L - $
Taxi receipt enclosed
Receipt enclosed
From:
yes
yes
no
no
To:
no
no
If
why?
If
why?
D - $
Reason:
Date
Public
B - $
Taxi
(dd/mm/yyyy)
Transit
AM
PM
Time:
$
$
L - $
From:
Taxi receipt enclosed
Receipt enclosed
yes
no
yes
no
To:
no
no
If
why?
If
why?
D - $
Reason:
Date
Public
Taxi
B - $
(dd/mm/yyyy)
Transit
AM
PM
$
Time:
$
L - $
Taxi receipt enclosed
From:
Receipt enclosed
yes
no
yes
no
To:
no
no
If
why?
If
why?
D - $
Reason:
Date
Public
Taxi
B - $
(dd/mm/yyyy)
Transit
AM
PM
Time:
$
$
L - $
Receipt enclosed
From:
Taxi receipt enclosed
yes
no
yes
no
To:
no
no
If
why?
If
why?
D - $
Reason:
Date
Public
Taxi
B - $
(dd/mm/yyyy)
Transit
AM
PM
Time:
$
$
L - $
From:
Taxi receipt enclosed
Receipt enclosed
yes
no
yes
no
To:
no
no
If
why?
If
why?
D - $
Reason:
A.
B.
C.
D.
Mileage Rates:
Before 01Jan2001 ($0.22/km)
(rate X km)
TOTALS:
Between 01Jan2001 to 31Dec2005 ($0.34/km)
$
$
$
$
Between 01Jan2006 to 31Dec2008 ($0.37/km)
Between 01Jan2009 to 31Dec2013 ($0.38/km)
$
Total of Expenses (A + B + C + D)
From 01Jan2014 ($0.40/km)
C. Worker Declaration
I hereby certify that the information provided on this form is true, accurate and complete, and that the travel details provided were incurred by myself and are
directly related to my WSIB case. I agree to provide all original receipts to the WSIB. I also authorize the release of any information to the WSIB relating to the
travel details and expenses listed on this form.
Type your name and upload, or print and sign before returning to WSIB.
Signature
Date
2721A (12/13)
WTEFF
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