2025 Healthy Lifestyle Reimbursement Request Form

The Healthy Lifestyle Reimbursement Program is open to all regular (non‐temporary) WPPI employees. Eligible employees can receive a reimbursement of up to $50 per calendar year for qualified expenses incurred during that calendar year.

The following are examples of qualified expenses under the Healthy Lifestyle Reimbursement Program:
1. Gym Memberships
2. Fitness Classes
3. Weight Watchers, YMCA nutrition and/or physical fitness programs, etc.
4. Participation Fees for Runs/Walks
5. Fitness Equipment
6. CSA Memberships
7. State Park or Trail Passes

IMPORTANT NOTE: Should you have questions about whether or not a particular expense qualifies for reimbursement, it is important you contact Nicole Vant Hoff or Julie Zacher to confirm PRIOR TO incurring the expense and submitting for reimbursement, as some expenses may not qualify.

Healthy Lifestyle Reimbursement Request Form

Name(Required)

First Last

Email(Required)

Description of expense for which you are requesting reimbursement:(Required)

Explanation of how this activity/item fulfills the primary purpose of promoting physical health and wellbeing:(Required)

Amount of Reimbursement:(Required)

Date expense was incurred:(Required)

Employee Signature:(Required)

**Please note that reimbursements are paid via payroll and are subject to standard taxation; based on the timing that this form was received, HR will process on the next possible payroll.**

Date:(Required)

Attach receipt or paid invoice:

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