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Dartmouth College/Cigna Fitness Benefit

If you have CIGNA benefits, we’ve got a healthy incentive for you!

As a customer of the CIGNA Medical Plan, you are eligible for a fitness reimbursement of up to $200 per calendar year (combined family maximum) in qualified fitness facility membership fees or exercise class fees.

What kind of Fitness Facility Membership Qualifies?

Start exercising your option by picking a fitness facility that works for you. Examples of facilities that qualify include full service fitness facilities (with an array

of cardiovascular and strength-training exercise equipment) as well as martial arts centers, yoga studios, gynmastics facilities, tennis, aerobic or pool only facilities and programs with a qualified personal trainer. Fees paid for attending aerobic/fitness classes at a qualified fitness facility without an annual membership will also be covered.

The fitness reimbursement is for fitness activities that occur 2 times per week, for at least 10 out of 20 weeks. A Fitness Reimbursement Log Card with instructor/facility sign-off must be submitted along with the Fitness Reimbursement Form, and receipts, to Cigna.

Here's what you need to do:

Simply send the following items to CIGNA:

iFitness Reimbursement Form (attached), answering all questions (please note that the $200 is per family* per calendar year).

iDated, original receipts from your fitness facility, or copies of bank or credit card statements if you pay by electronic fund transfer, showing:

The member's name

Individual charges demonstrating a minimum of 10 weeks participation

A copy of your Fitness Reimbursement

Log Card (attached)

iSign and date the completed Fitness Reimbursement Form, then mail us all of the above.

iYou can submit once you have met the criteria of working out at least 2 times per week for a minimum of 10 out of 20 weeks.

Please be sure to submit your form, log card and

receipts for reimbursement within 90 days of the of the calendar year.

Always consult a physician before beginning any new exercise program.

Reimbursement will be provided based on receipts you accumulate and submit up to a $200 limit per

family* each calendar year. Reimbursement forms and receipts must be completed and submitted within 90 days of the

end of the calendar year.

* Family = adult member age 18 +

Dartmouth College/Cigna Fitness Reimbursement Form

PLEASE PRINT ALL INFORMATION CLEARLY

CIGNA ID Number	Last Name	First Name	Middle Initial

Address ‐ Number & Street	City	State	Zip Code

Employer's Name Dartmouth College

Gender:

Male

Female

Date of Birth (MM/DD/YYYY):

WHEN TO SUBMIT FORM

After you have met the criteria of working out at least 2 times per week for a minimum of 10 out of 20 weeks After you have collected $200 in receipts from qualified fitness facilities

Once per calendar year

Please be sure to submit your reimbursement form, log card and receipts for reimbursement within 90 days of the end of

the calendar year.

CLUB/CLASS INFORMATION REQUIRED (Attach itemized receipts)

Name and Address of fitness facility

Dates of Service

Amount Charged

TOTAL NUMBER OF RECEIPTS ATTACHED:		TOTAL CHARGES: $

All Fitness Benefit payments will be sent to the Customer's address on file.

CERTIFICATION AND AUTHORIZATION (This form must be signed and dated below)

I authorize the release of any information to CIGNA about my health club membership. I certify that the information provided in support of this submission is complete and correct and that I have not previously submitted for these services.

Cigna Customer Signature/Member's Signature:

Date:

Please mail to the below address. Please also allow up to four weeks for processing.

CIGNA

Attn: Debra Sargent

2 College Park Drive

Hooksett, NH 03106

Note: If services are denied, a denial letter will be sent to the customer’s home address. Please be sure to keep copies of your form and receipts, we will not return any receipts or claims forms.

Dartmouth College / Cigna Fitness Reimbursement Log Card

Name:________________________________________________________________________________

Address:______________________________________________________________________________

Phone Number:_________________________________________________________________________

Cigna ID #:____________________________________________________________________________

All workouts must be logged in the same calendar year.

To qualify, you must exercise a minimum of two times per week for 10 out of 20 weeks.

(To meet exercise requirements within a calendar year, this log card must be

started no later than October 22nd of a given calendar year).

Return Log Card along with Fitness Reimbursement Form and Receipts to:

Cigna Healthcare – Attention: Debra Sargent

2 College Park Drive

Hooksett, NH 03106

FITNESS LOG

Record daily exercise here.

CARD

(Fitness Facility Employee / Instructor confirmation initials go inside the box.)

Record dates at the

Day 1

Day 2

beginning of each

week here

Exercise

Initial

Exercise

Initial

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9

Week 10

Week 11

Week 12

Week 13

Week 14

Week 15

Week 16

Week 17

Week 18

Week 19

Week 20

Electronic copies verifying attendance, printed on fitness facility letterhead, will also be accepted.

Question	Answer
Form Name	Cigna Gym Reimbursement Form
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	cigna gym membership discount, cigna fitness program, cigna gym discount, cigna insurance gym membership

Cigna Gym Reimbursement Form – Fill Out and Use This PDF

Cigna Gym Reimbursement Form PDF Details

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Cigna Gym Reimbursement Form – Fill Out and Use This PDF

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