HR Gym Reimbursement - Create A New Application - Franklin County Benefits and Wellness

Q1 2025 Gym Membership Reimbursement Form

In order to process your application, we ask you to provide the following information. Please note that all fields marked with an asterisk (*) are required.

Employee Information

First Name (please enter your legal name, no nicknames)*

Last Name *

Email Address *

Agency *

Hired Less Than Six Months Ago

Date of Birth *

Month Hired *

;

Employee ID/MUNIS ID *

Last 4 Employee SSN *

Check the box if you are submitting a request for a spouse/domestic partner (not employee) membership

Reminder: one person per household eligible per month (except households with two employees).

Gym Information

Gym Name *

Additional Gym

Attendance/Payment

If combining visits from multiple gyms, please provide your total attendance and cost for each month.

January Attendance *

January Monthly Charge *

February Attendance *

February Monthly Charge *

March Attendance *

March Monthly Charge *

Reimbursement rates:
0-3 visits per month - no reimbursement
4-7 visits per month - 50% of monthly membership cost, up to $25/month
8+ visits per month - 100% of monthly membership cost, up to $50/month

Total Reimbursement Request

Amount requested for reimbursement *

Based on the information provided above, this is the amount of reimbursement you are eligible for. If you have questions or concerns please contact ThriveOn at [email protected] or 614-525-3948.”

Proof of Attendance and Proof of Payment

Proof of attendance and proof of payment is required for reimbursement.
Documents must include your name, your gym name, the dates visited each month, and the amount paid each month.
If you are combining visits from two gyms you must fill out the gym information section and provide documentation from both memberships.

Please upload documents only in 'csv, 'doc', 'docx','gif, 'jpg', 'jpeg', 'pdf', & 'png' format.

Documents

(Please select one file at a time)

Please upload valid file

Upload document

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Required Signature

Please check the box to provide your digital signature.

Signed Date

03/31/2025

By checking this box I affirm that all of the information provided is full, complete and true to the best of my knowledge. False statements are considered fraud against the plan. I acknowledge that checking this box serves as my signature.