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COMMUTER PLAN CLAIMS Customer Service information such as (College of Alameda)

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©2019 Pension Dynamics Company LLC. All rights reserved.
COMMUTER PLAN CLAIMS
Customer Service
The best way to check your claim status is to log into your account online at
www.pensiondynamics.com. If you have not yet registered for an account, please contact
Pension Dynamics Company LLC. The website is available 24/7 and is a great resource
once you have registered.
Customer Service is available at (925) 956-0514 from 8 AM - 5 PM PST, Monday - Friday.
You can also email us at benefits@pensiondynamics.com. Please include your name and
your employer name on any correspondence sent to us but do not include confidential
information such as your Social Security Number.
Important information before you begin
CONTACT INFORMATION
Benefits Department
Phone: (925) 956-0514
Fax: (844) 859-7309
Email: benefits@pensiondynamics.com
Address:
2300 Contra Costa Blvd., Suite 400
Pleasant Hill, CA 94523
Website: www.pensiondynamics.com
Tips for Completing the Claim Form
• Fill out each section completely. Any incomplete forms will not be able to be processed.
• Type or write legibly.
• Don't forget to sign your form. The employee who is participating in the plan is required to sign the form, not your spouse or other
dependent.
• Expenses can only be incurred by the employee, not your spouse or other tax dependent.
• This is a monthly benefit with a monthly limit. Claims MUST be submitted by month or partial month, but not spanning multiple
months, and must include the year. For example: January 2016 - OK; January 15-31, 2016 - OK; January 15 - February 15 - NOT OK.
Things to Include with your Claim
• Fully completed and signed Claim Form.
• Receipt for each expense which includes the date of service. Receipts must be submitted unless they are not provided in the
normal course of business. If this is the case, circle NO under the Receiptable portion of the Claim Form.
• Canceled checks and credit card receipts are not acceptable receipts under IRS regulations.
Reminders for Submitting your Claim Form:
• Retain the original of all requests including the substantiation, sending us a copy of the documents only. Pension Dynamics is not
responsible for providing copies.
• Please allow 2 business days for your claim to be processed. Payments are not able to be issued until after services have been
incurred in full.
• If your claim is denied, you will receive a message online explaining why the claim could not be processed. If we need further
information, the denial letter will state what you can do in order to have your claim re-processed within 180 days.
• Do NOT combine your claim with your co-workers' claims. It will not be processed.
• To submit, complete the Claim Form and attach all substantiation. You may upload the documents to secure.pensiondynamics.com
or you can download our mobile application. This can be found by searching "Pension Dynamics WealthCare" in your app store.
• You may also Fax your Claim in it's entirety to (844) 859-7309 with a cover page.
• You may also mail a copy of your Claim in it's entirety to: Pension Dynamics Company LLC, Attn: Benefits Department, 2300 Contra
Costa Blvd., Suite 400, Pleasant Hill, CA 94523-3987.
secure
.pensiondynamics.com
©2019 Pension Dynamics Company LLC. All rights reserved.
COMMUTER REIMBURSEMENT
FAILURE TO COMPLETE THIS FORM IN FULL MAY DELAY PAYMENT
Plan Name:
Example "ABC Company 132(f) Tax-Free Transportation Plan" If you are unsure about your Plan Name please contact your human resources or benefits department.
Name
SECTION 1. EMPLOYEE INFORMATION
Last Four Digits of SSN
Evening Phone NumberPersonal E-mail Address Daytime Phone Number
SECTION 2. TRANSPORTATION CLAIMS (CLAIMS CANNOT EXCEED $265/MONTH)
• These expenses must be for a pass, token, fare card, voucher, or similar item for transportation either on mass transit facilities (including BART,
Muni, ferry, cable car, etc.) or in a Commuter Highway Vehicle (Vanpool).
• A Commuter Highway Vehicle is any highway vehicle with a seating capacity of at least six adults (not including the driver), and for which at least
80% of the mileage is for the purposes of transporting employees between their residences and their place of employment.
• Individual carpool, bridge toll, or taxi fare does NOT qualify.
• The transportation must be for travel between your residence and/or public transportation location (i.e. Bart station, VanPool) and place of
employment.
Provider / Vendor Month/Year of Service
Receiptable
Yes No
Requested Amount
Total:
If you need additional space to list expenses, please use another form.
• “Parking expenses” are defined as expenses incurred to park your car on or near the business premises of your employer, or expenses incurred to
park your car at a location from which you commute to work by mass transit, Commuter Highway Vehicle (Vanpool), or carpool.
SECTION 3. PARKING CLAIMS (CLAIMS CANNOT EXCEED $265/MONTH)
Provider / Vendor Month/Year of Service
Receiptable
Yes No
Requested Amount
Total:
If you need additional space to list expenses, please use another form.
I request reimbursement for the above expenses. I certify that any transit and/or vanpooling expense claimed on this form is for the purpose of
transportation for me to and from my place of employment. Any vanpooling is in a vehicle with a seating capacity of 6 or more adults (not
including the driver), and at least 80% of the mileage is for the transportation of employees in connection with travel between their residences
and their places of employment.
I certify that the parking expenses submitted on this claim form for reimbursement are for my automobile to be parked either at a site near my
place of business or for a parking space from which I commute by public transit, van, or carpool. The parking space is not near my place of
residence.
I certify that I have included any available proof of the claims that I have made above. The claims made here are pursuant to IRS Code Section 132
and I understand that any falsification is subject to penalty under law.
I hereby certify that all of the above claim information is true and correct and compliant with the rules of the plan:
Date
Employee Signature
Submit electronically: https://secure.pensiondynamics.com/ or Fax: (844) 859-7309
SECTION 4. EMPLOYEE AUTHORIZATION
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Completed 25 July 2020

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