Commuter Claim Form - Wageworks Page 2
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2Commuter Benefits
Pay Me Back Claim Form
TOLL-FREE FAX:
(877) 353 - 9236
Or, mail to: Claims Administrator, PO Box 14053, Lexington, KY 40512
ACCOUNT HOLDER INFORMATION
Last Name
First Name
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ID Code (last 4 digits)
Employer / Program Sponsor's Name
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Birth Month/Day (MM/DD)
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CERTIFICATION AND AUTHORIZATION
My signature certifies that
The information on this page is accurate and complete.
1
I am requesting reimbursement for my own personal expenses.
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These services have already been provided.
3
I have not and will not seek reimbursement of this expense from any other plan or party.
4
If No Receipt Provided is checked, this service provider does not provide receipts (such as payments made by token/ticket machine, meter or cash
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box).
6
If Use Balance to Pay for Next Commuter Order is checked, I request that any remaining balance for the benefit month indicated be turned into a
credit that will reduce my next pre-tax payroll deduction.
If this is a Public Transportation expense, then the pass for this service in this amount is not available for purchase from WageWorks.
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Use of this service indicates my acceptance of the WageWorks User Agreement at (available upon registration; enter user
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name and password or click on First Time User? link).
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CLAIMS FOR OUT-OF-POCKET EXPENSES
Parking
1
$
Vanpool
Pub Trans
Name of Parking Facility or Service Provider
Benefit Month (MM/YY)
Out-of-Pocket Cost
No Receipt Provided
Use Balance to Pay for Next Commuter Order
If so, you can file online claim instead.
If not, you can still file claims for this Benefit Month (up to available balance).
Parking
2
$
Vanpool
Pub Trans
Name of Parking Facility or Service Provider
Benefit Month (MM/YY)
Out-of-Pocket Cost
No Receipt Provided
Use Balance to Pay for Next Commuter Order
If so, you can file online claim instead.
If not, you can still file claims for this Benefit Month (up to available balance).
Parking
3
$
Vanpool
Pub Trans
Name of Parking Facility or Service Provider
Benefit Month (MM/YY)
Out-of-Pocket Cost
No Receipt Provided
Use Balance to Pay for Next Commuter Order
If so, you can file online claim instead.
If not, you can still file claims for this Benefit Month (up to available balance).
* Your ID Code is the last 4 digits of your Social Security Number, your Employee Number or other reference
number assigned by your program sponsor. Please check the enrollment instructions provided by your program
$
sponsor for more information about your ID Code.
TOTAL THIS FORM
YOU MUST ATTACH APPROPRIATE PROOF OF SERVICE FOR EACH AMOUNT ABOVE OR CHECK "NO
RECEIPT PROVIDED."
Sign this 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.
WW-COM-0907-PMB
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