Miscellaneous Reimbursement Form

All Other Items Reimbursement Form

  • Please note that in emailing this form to Gallagher Bassett from your designated email account, you declare that you have paid for this service and that the details of this form are true and correct and are related to your compensable disability. If insufficient evidence is received, we will not pay until relevant information is provided.
  • Item DescriptionFor What Injury (eg elbow) 
  • Drop files here or
    Please note that in sending this form to Gallagher Bassett you declare that you have paid for the item/s listed and that the details of this form are true and correct and are related to your compensable disability. If insufficient evidence is received, we will not pay until relevant information is provided.
  • If you wish to receive payment electronically please provide your account details below: