Commuter Claim Form - Wageworks

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Commuter Benefits
Pay Me Back Claim Form
TOLL-FREE FAX:
(877) 353 - 9236
Or, mail to: Claims Administrator, PO Box 14053, Lexington, KY 40512
WageWorks Pay Me Back Claim Form Instructions
PLEASE READ THIS BEFORE SUBMITTING YOUR CLAIM FORM
Your claim is important, but in order for us to process it and your reimbursement quickly and fully, we need
you to completely and accurately fill out and submit the WageWorks Pay Me Back (PMB) claim form. To help
you, we’ve provided the below guidelines. Please follow them when completing and submitting your claim.
Tips for Filling out the Pay Me Back Claim Form
• Do not file a claim for any pass purchased through WageWorks or for parking paid using the Pay My
Parking service
• Read every box and provide all requested information pertaining to you and your claim
• Provide the legal name your employer has for you in your official records, not your nickname
• Be sure to complete a separate line for each month when filling in your claim forms (e.g. $120 for January,
$150 for February). Do not submit an annual amount or date range
• Make sure to total the reimbursement amount and enter it at the box at the bottom of the form
• Make sure you sign the form
Things to Remember When Including Receipts
• Include a receipt for every expense
• A canceled check is not an acceptable form of receipt
• Each receipt must include the date(s) of service
• Do not send original receipts; keep them for your own records
• If you attach multiple receipt pages, circle or check the dollar amount that is being claimed for each receipt
• Do not use a highlighter to highlight the dollar amount on the receipt
Tips for Submitting the Pay Me Back Claim Form by Fax
• Do not use a cover page
• Use a high-speed fax machine with a transmission speed of at least 9.6 kbps or 15 sec. per page
• Do not combine and submit a co-worker’s claims with yours
Sign the form.
Send a photocopy of your receipt.
Keep original receipt with a copy of this completed form.
Do not file a claim for any pass purchased through WageWorks or for parking paid using Pay My Parking.

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