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  • Unicare Ec729 2018

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Page 1 Fitness Club Reimbursement Form 1. Enrollee name Last First MI 2. Enrollee address 3. Member ID from UniCare ID card 4. Enrollee birth date 5. Member name if different from enrollee 6. Name of fitness club 7. Member s relationship to enrollee 8. Requested reimbursement amount 9. What months are you requesting reimbursement for Example 7/2018 through 12/2018 Write your member ID on all paperwork. Send this form and your proof of payment to UniCare State Indemnity Plan PO Box 9016 Andover MA 01810-0916 See page 1 for instructions. Upon proof of payment the reimbursement is paid to the Plan enrollee subscriber. What types of fitness clubs qualify Eligible for reimbursement Not eligible for reimbursement Health clubs and gyms that have cardio / strength-training machines as well as other programs for improved physical fitness Beach clubs Country clubs Dance classes/studios Exercise machines Gymnastics centers Martial arts centers Personal trainers Sports coaches Sports teams/leagu....

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Related content

UniCare Fitness Reimbursement - Westford, MA
... at a fitness club. UniCare will reimburse the Plan enrollee (subscriber) once each...
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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Unicare EC729
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