"Reimbursement Form - Weight Watchers" - Virginia

Reimbursement Form - Weight Watchers is a legal document that was released by the Virginia Department of Human Resource Management - a government authority operating within Virginia.

Form Details:

  • Released on November 1, 2015;
  • The latest edition currently provided by the Virginia Department of Human Resource Management;
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Commonwealth of Virginia
Weight Watchers® Reimbursement Form
Revised 011/15
This form must be completed to receive your Weight Watchers
reimbursement.
®
Reimbursements are limited to three per person per year.
[ ]Monthly Pass for At Work and Local Meetings
(Attach your Account History [call 1-866-204-2885], At Work receipt or copies of at least 3 months of Monthly Passes)
Weight Watchers Leader or Receptionist completes this section for certification of program:
I certify that ________________________ has purchased (a _____week series/months) from ________ to
_________ at a
Start Date
End Date
total price of $_________ and has achieved the required participation level to receive reimbursement.
______________________________________
_____________________
_____________
Weight Watchers Leader/Receptionist Signature
Meeting Location Number
Date
[ ]Online subscription
Total amount paid $_________from _________to________
(Attach your Account History)
Start Date
End Date
EMPLOYEE VERIFICATION SECTION
Please fully complete and submit this form to the address below. You acknowledge and agree to the following Terms and
Conditions: Reimbursement form is valid in participating areas only. Void where prohibited or restricted by law. Availability and
terms of reimbursement may change without notice. Reimbursements are taxable income. For more information on tax implications,
go to
http://commonhealth.virginia.gov/weightwatchers.htm.
The information on this reimbursement form will not be used for any
employee specific purpose other than processing the reimbursement. Keep copies of all materials submitted. The Commonwealth is
not responsible for lost, late or misdirected mail sent by employees. Reimbursements are typically processed four times a year,
in March, June, September and December.
Employee Verification (Please Print Clearly)
□□□□□□□□□
□□□
3-Digit Agency Code
Employee ID # (up to 9 numbers shown on Payline or your
health plan ID card, NOT another form of employer ID)
State Agency Name
_______________________________________________________________________________________________________
Employee Name
_______________________________________________________________________________________________________
Employee Home Address
_________________________________________________
_______________
__________________
City
State
Zip Code
________________________________________________
____________________________________________
Employee Work E-Mail Address
Employee Phone
Complete online and send with scanned
Please note: Only state employees may be reimbursed—no retirees, spouses, de-
receipt(s) to
employeeevents@dhrm.virginia.gov
pendents or The Local Choice members. Employees on layoff may continue partici-
or mail completed form with receipt(s) to:
pation in the Weight Watchers online and local status meetings. However, those in
Virginia Department of
an At Work program must transfer to another option by calling Weight Watchers at
Human Resource Management
1-866- 614-9129. Reimbursement will be honored only for the employee’s current
ATTN: Office of Employee Programs
session if all requirements are met. Send questions to wellness@dhrm.virginia.gov.
101 N. 14th Street, 12th Floor
Richmond, VA 23219
Commonwealth of Virginia
Weight Watchers® Reimbursement Form
Revised 011/15
This form must be completed to receive your Weight Watchers
reimbursement.
®
Reimbursements are limited to three per person per year.
[ ]Monthly Pass for At Work and Local Meetings
(Attach your Account History [call 1-866-204-2885], At Work receipt or copies of at least 3 months of Monthly Passes)
Weight Watchers Leader or Receptionist completes this section for certification of program:
I certify that ________________________ has purchased (a _____week series/months) from ________ to
_________ at a
Start Date
End Date
total price of $_________ and has achieved the required participation level to receive reimbursement.
______________________________________
_____________________
_____________
Weight Watchers Leader/Receptionist Signature
Meeting Location Number
Date
[ ]Online subscription
Total amount paid $_________from _________to________
(Attach your Account History)
Start Date
End Date
EMPLOYEE VERIFICATION SECTION
Please fully complete and submit this form to the address below. You acknowledge and agree to the following Terms and
Conditions: Reimbursement form is valid in participating areas only. Void where prohibited or restricted by law. Availability and
terms of reimbursement may change without notice. Reimbursements are taxable income. For more information on tax implications,
go to
http://commonhealth.virginia.gov/weightwatchers.htm.
The information on this reimbursement form will not be used for any
employee specific purpose other than processing the reimbursement. Keep copies of all materials submitted. The Commonwealth is
not responsible for lost, late or misdirected mail sent by employees. Reimbursements are typically processed four times a year,
in March, June, September and December.
Employee Verification (Please Print Clearly)
□□□□□□□□□
□□□
3-Digit Agency Code
Employee ID # (up to 9 numbers shown on Payline or your
health plan ID card, NOT another form of employer ID)
State Agency Name
_______________________________________________________________________________________________________
Employee Name
_______________________________________________________________________________________________________
Employee Home Address
_________________________________________________
_______________
__________________
City
State
Zip Code
________________________________________________
____________________________________________
Employee Work E-Mail Address
Employee Phone
Complete online and send with scanned
Please note: Only state employees may be reimbursed—no retirees, spouses, de-
receipt(s) to
employeeevents@dhrm.virginia.gov
pendents or The Local Choice members. Employees on layoff may continue partici-
or mail completed form with receipt(s) to:
pation in the Weight Watchers online and local status meetings. However, those in
Virginia Department of
an At Work program must transfer to another option by calling Weight Watchers at
Human Resource Management
1-866- 614-9129. Reimbursement will be honored only for the employee’s current
ATTN: Office of Employee Programs
session if all requirements are met. Send questions to wellness@dhrm.virginia.gov.
101 N. 14th Street, 12th Floor
Richmond, VA 23219