Travel Reimbursement Form

Travel Reimbursement (NT)

Please use for Northern Territory Claims Only
  • 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.
  • Date of TravelFrom: SuburbTo: Name & SuburbReason for TravelMeans of TravelCost or DistanceProvider Name and Company NameAdditional Information e.g. detour due to road works 
  • Drop files here or
    If you are claiming for fares paid for public transport, please attach tickets If you are claiming for the use of your own car, show the distance travelled for each trip to the nearest 1/10th of a kilometre Important: Write your claim number and Return to Work Specialist or Claims Officer’s name on all receipts
  • Date of MealReason for Travel 
  • Drop files here or
    If you are claiming for meals please attach receipts
  • If you wish to receive payment electronically please provide your account details below: