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Wellness Reimbursement Request Date: Current Date. Employee: First Last Department: Department Supervisor: Supervisor. Employee Job Information Position: Contract Job Title Status: Full-time Y/N Date of Hire: Work Type: Hourly ? Salary ? Shift Type: Day ? Night ? Swing ? Other ?

Supervisor must complete the following form and file it with the Human Resources Department. Employee must provide receipt(s) for all reimbursed wellness activities. Description of Wellness Program or Activities Describe the wellness program or activities you are seeking reimbursement for. Qualifications Does employee have receipt(s) of payment for the activities being submitted for reimbursement? Yes ? No ? Are the activities submitted for reimbursement "Qualified Wellness Program" activities? Yes ? No ?

Qualified Wellness Program Activities

Purpose of Company Name Wellness Reimbursement Plan:

The purpose of this plan is to provide our full-time employees with financial incentives and assistance to encourage participation in health and wellness activities and programs, such as health club memberships, aerobic / exercise classes, health education classes, and smoking and tobacco cessation or weight management programs.

Who can participate in Wellness Reimbursement:

Full-time, regular employees are eligible to participate in the wellness reimbursement program. The maximum benefit an employee can receive is limited to Insert $ Amount/month for all qualified activities. For an activity to be considered "qualified," the employee must participate in the activity for three consecutive months to be eligible for reimbursement.

The company will also reimburse any previously paid qualified wellness expense so long as it is within six months of the reimbursement request, subject to documentation requirements.

The following activities shall be excluded from the Wellness Reimbursement plan:

Recreational sports programs (unless included in health club membership dues). Recreational sports events (including marathons, triathlons, tournaments). Personal trainer fees and personal fitness or sports equipment.

Classes, training, or instruction that is not provided by a licensed business or instructor (proof may be required). Meals, supplements, or aids for weight loss, body building, or for smoking / tobacco cessation. Massage programs. Medical treatment programs or therapy.

Psychological treatment programs or therapy. Fees, finance charges, late fees or other charges not a part of regular health club or classroom dues.

Payment Requirements:

All reimbursement requests must have a paid receipt showing the wellness activity purchased, date of purchase, the business Tax ID, and the period of time that the purchase covers. For multi-month purchases made up front, company shall reimburse up to Insert $ Amount/month, paid on a quarterly basis. Company will reimburse only wellness expenses incurred during employment with Company Name.

Expenses prior to employment with Company Name shall not be considered. Company reserves the right to request additional information or documentation on all requested reimbursements. Company may also deny a reimbursement expense if that expense is determined to be covered under an applicable health insurance plan or other reimbursable program. Employees may not submit a wellness reimbursement request for any expense that has already been submitted or paid out through a Flexible Spending Account (FSA), Health Savings Account (HSA), or Medical Reimbursement Account (MRA).

If you have any questions concerning the eligibility of any wellness expense, please consult the Human Resources Department.