Name Member Number Mailing Address

If my submission is for more than $360 per year or takes my total reimbursement for the year over $360, I understand I will only be reimbursed for up to $360.

 
Attach a dated receipt showing the charge and the name of the fitness activity:
 

Be Fit will not cover services that require additional fees, like personal equipment. It applies only to standard fitness class and gym membership fees at non-residential commercial or community facilities, and it does not go toward your out-of-pocket maximum.

Roster Entry - Internal Use Only

How Be Fit Works

With Be Fit get paid back for a variety of fitness activities. You choose how you want to work out, and we pay you back up to $360 a year. Submit your receipts with 365 days of receipt date.

If your receipt is for a family membership or multiple fees over $360, we will reimburse you up to $360. Or, if it’s clear which portion of the charge is for you, we will reimburse you for that amount up to $360.