Hartford Fitness Reimbursement

Member Information

Please verify and complete the member information below. All submissions must be submitted by midnight ET on the 10th calendar day after the close of the calendar quarter

First Name

Last Name

Email Address

Phone Number

Fitness Activity Information

I confirm that I am requesting reimbursement for a qualifying activity.

Participation at fitness centers, health clubs or aquatic centers as well as session fees for such activities as group/personal training, Pilates, yoga instruction, etc. when offered by a certified instructor, are eligible for reimbursement.

Martial arts centers, gymnastic facilities, country clubs, tennis clubs, sports teams and leagues, online workouts or videos, and the purchase of exercise equipment are NOT eligible for reimbursement.

Reimbursement Information

Quarter for Which Reimbursement is Being Requested

Total Reimbursement Amount

Proof of Payment / Receipts

Attach proof of purchase and/or receipts. Please note Virgin Pulse is unable to accept form submissions containing sensitive information (i.e., bank routing numbers, credit card statements including credit card number and account numbers). Any submission containing sensitive data will be deleted and you will not be eligible for the fitness reimbursement program unless you resubmit a complete set of required documents with any sensitive information redacted before the quarterly deadline.

Proof of Payment/Receipt*

Maximum of 12 receipts

Certification and Authorization

I authorize the release of any information to Virgin Pulse, Inc. about my fitness reimbursement. I certify that the information provided in support of this submission is complete and accurate.

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