Healthy Lifestyle Reimbursement Claim Form
Healthy Lifestyle Reimbursement Claim Form
Your Name
*
First Name
Last Name
Email Address
*
example@example.com
Department
*
Please Select
Human Resources
Finance
Engineering
Marketing
Sales
Operations
Other
Expense Category
*
Please Select
Fitness membership or class
Sports or exercise equipment
Wellness activity
Other eligible lifestyle expense
Date of Expense
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Merchant or Provider
*
Describe the Expense
*
Amount Requested
*
Upload Receipt or Supporting Document
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Additional Notes
Submit Claim
Should be Empty: