TAXI INVOICE M

This invoice must be submitted within 90 days of the date of service. All fields with * are required for payment to be processed. F
information may result in processing delays or in non-payment. All other fields to be completed (if possible). Incomplete invoices may
resubmission.
PAYMENT SERVICES FAXMAIL
Phone 604 276-3085 604 233-9777
Payment Services, WorkSafeBC
Toll-free 1 888 422-2228 Toll-free 1 888 922-8807 PO Box 4700 Stn Terminal
Vancouver BC V6B 1J1
Invoice number

Invoice date (yyyy-mm-dd)

Authorization number

Service recipient information (worker or other person who received service)

Service recipient last name*

Service recipient first name*

Payment information
Payee name
Mailing address for payment

City

Phone number (include area code)

Fax number (include area code)

Service information

Date of service*
(yyyy-mm-dd)

Fee
code*

Origin*

Destination*

Number
of
units*

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1
Page 1 total*

WorkSafeBC use only

Payment officer initials

(R13/07) Page 1 of 6

83D192

Personal information on this form is collected for the purposes of administering a workers compensation claim by WorkSafeBC in accordance with the Workers Compensation Act and the Fr
Protection of Privacy Act. For further information about the collection of personal information, please contact WorkSafeBCs Freedom of Information Coordinator at PO Box 2310 Stn Terminal
telephone 604 279-8171.

TAXI INVOICE M

Service recipient last name*

Service recipient first name*

Service information (continued)

Date of service*
(yyyy-mm-dd)

Fee
code*

Origin*

Destination*

Number
of
units*

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1100546

1
Page 2 total*

WorkSafeBC use only

Grand total*

Payment officer initials

0

(R13/07) Page 2 of 6

83D192

(R13/07) Page 3 of 6

83D192

AXI INVOICE MULTIPLE TRIPS

yment to be processed. Failure to provide this

). Incomplete invoices may be returned for

GST registration number

WorkSafeBC claim number*

Payee number*
Province

Line item
total*
(including taxes)

Postal code

GST
amount*

Line item
amount*
(not including
taxes)

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

(R13/07) Page 4 of 6

83D192

Workers Compensation Act and the Freedom of Information and

ordinator at PO Box 2310 Stn Terminal, Vancouver BC, V6B 3W5, or

AXI INVOICE MULTIPLE TRIPS

(continued)

WorkSafeBC claim number*

0
Payee number*

Line item
total*
(including taxes)

GST
amount*

Line item
amount*
(not including
taxes)

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
0.00

(R13/07) Page 5 of 6

83D192

(R13/07) Page 6 of 6

83D192