Get Proof Of Participation

Proof of Participation. At Work or Community Meetings Ask your Weight Watchers leader or receptionist to certify and sign below I certify that has attended a minimum of weekly meetings. Weight Watchers Proof of Participation Form PEBB Employee to Complete - PLEASE NOTE NEW RENEWAL FAX NUMBER To qualify for another Weight Watchers series you must first fax this form to 1-888-598-7704 showing proof of participation in at least 10 weeks of your prior Weight Watchers series. No exceptions will be made. Follow the instructions below to rejoin Form must be filled out in its entirety to qualify. 1. Check the applicable Weight Watchers service you ve just completed I participated in at least 10 weeks of the following plan At Work Meeting Traditional Meeting Online Subscription Participation Dates Start Date End Date 2. Meeting Name/Location Date 3. Read Terms and Conditions Confirm Method of Return Communication and Sign* By providing the above information and submitting this form I acknowledge and agree to the following Terms and Conditions Offer is valid for submitted* Weight Watchers and PEBB are not responsible for lost late or misdirected forms. Upon receipt and validation of your request you will be reissued a new Weight Watchers Access Code which will allow you to rejoin Weight Watchers. The information submitted on this form will be used solely to process your request. All information is required Please print clearly Last Name First Name MI Health Plan ID Number Health Plan circle your plan PEBB Statewide Plan Providence Choice Kaiser Permanente Address CityStateZip Email Address Phone Number Please write clearly Signature Date 4. Preferred method of return communication must be completed to receive new renewal access code Call me at or Email me at this address If you have specific questions about your health plan please contact them directly at the number listed on your insurance card. No exceptions will be made. Follow the instructions below to rejoin Form must be filled out in its entirety to qualify. 1. Check the applicable Weight Watchers service you ve just completed I participated in at least 10 weeks of the following plan At Work Meeting Traditional Meeting Online Subscription Participation Dates Start Date End Date 2. Meeting Name/Location Date 3. Read Terms and Conditions Confirm Method of Return Communication and Sign* By providing the above information and submitting this form I acknowledge and agree to the following Terms and Conditions Offer is valid for submitted* Weight Watchers and PEBB are not responsible for lost late or misdirected forms. Upon receipt and validation of your request you will be reissued a new Weight Watchers Access Code which will allow you to rejoin Weight Watchers. Upon receipt and validation of your request you will be reissued a new Weight Watchers Access Code which will allow you to rejoin Weight Watchers. The information submitted on this form will be used solely to process your request. All information is required Please print clearly Last Name First Name MI Health Plan ID Number Health Plan circle your plan PEBB Statewide Plan Providence Choice Kaiser Permanente Address CityStateZip Email Address Phone Number Please write clearly Signature Date 4.