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2023 FITNESS REIMBURSEMENT PROGRAM
Follow these 3 easy steps:
What qualifies?
A membership at a full service health club, studio or fitness
program, as well as fitness classes held at a health club,
studio or recreation center, online fitness class
subscriptions (e.g. Beachbody, Daily Burn, and Peloton),
personal training sessions (personal training sessions in a
traditional health club/fitness studio only), fitness related
fees (e.g. pool membership and skiing season pass) and
eligible home exercise equipment.
Eligible home exercise equipment that provides
cardiovascular and/or muscular total‐body workout.
Equipment must be new and purchased through a retail
store which includes online. The following pieces of
equipment are eligible for reimbursement: home gyms,
treadmills, stationary cycles, elliptical machines, rowing
machines, stair climbing machines, and total body weight
resistance machines
.
What does not qualify
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muscle‐specific resistance equipment such as
abdominal rollers, thigh or buttocks machines, free
weights;
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exercise videos or mats;
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outdoor recreational equipment such as golf clubs,
bicycles, game balls, skates, skis, tennis racquets, or
rollerblades;
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exercise clothing or shoes and any used equipment;
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sport leagues (e.g. basketball league)
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fitness day pass, race entry fee, and individual
ski tickets
The above list is not a complete list, but
rather examples of ineligible expenses; Cigna
may deny a submission for an ineligible
expense.
Important Information
$300 is the maximum reimbursement amount per family per
calendar year. Family includes employee/retiree and
dependents who are covered under a USNH medical plan
administered by Cigna.
There is no attendance requirement, you can submit your
form and receipt/proof of purchase as soon as you make
an eligible purchase.
At the time of reimbursement, you must be a current USNH
employee or eligible retiree and be a participant in a USNH
Cigna medical plan to be eligible for this reimbursement.
Submission Process
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Employee/Retiree to complete, sign and date the
Fitness Reimbursement Program Form, submitted
once per calendar year.
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Include dated, original receipts from the fitness
program, online fitness class subscription, retail
store, or copies of bank/ credit card statements
(black out any reference to account or credit card
numbers) showing:
− The participant name.
− Name of facility.
− Individual charges of each fitness program,
member membership, or class fees.
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Charges and dates of each session or
monthly membership.
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Proof of purchase that clearly shows the
amount you paid.
Membership/class expenses will be pro‐rated to only
reimburse for the current 2023 calendar year if the
actual expense paid included prior year or future year
membership/ class expenses. Home exercise equipment
purchased outside the current plan year is not eligible
for reimbursement.
The completed form must be postmarked by
March 31, 2024.
UNIVERSITY SYSTEM OF NEW HAMPSHIRE
Get reimbursed up to $300 per family per calendar year for eligible fitness expenses. Employees/Retirees and
dependents are eligible for the Fitness Reimbursement Program if they participate in the University System of New
Hampshire (USNH) medical plan administered by Cigna.
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MAKE AN ELIGIBLE
PURCHASE
COMPLETE
FORM
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Section 1 – Employee/Retiree Information
Last Name First Name Middle Initial
Home Address ‐ Number & Street City State Zip Code
Employee USNH ID:
Cigna ID Number
Date of Birth (MM/DD/YYYY):
Section 2 – Eligible Expenses
Fitness Program Expense
Dates of Service
or Purchase
Participant Name
Amount Paid
Total number of receipts attached: Total Amount requested: $ (max of $300)
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 accurate and has not been previously submitted.
I understand reimbursements will be provided via USNH payroll and are subject to applicable tax withholdings.
Employee/Retiree Signature: Date:
Please mail this form and all copies of your receipts to the below address. Please allow 3‐4 pay cycles to receive your reimbursement
via USNH payroll. The Fitness Reimbursement is taxable. If you have any questions about your submission, please call 1.800.244.6224
Customer Service.
Cigna
Health Promotions/USNH
1750 Elm Street, Suite 800
Manchester, NH 03104
Please make sure to keep a copy of your form and receipts as proof of submission if validation is required from Cigna. Cigna will not return any
receipts or forms. If services are denied, a denial letter will be sent to the employee/retiree’s home address.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company,
Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo,
and other Cigna marks are owned by Cigna Intellectual Property, Inc. 04/22/22 © 2022 Cigna.
2023 FITNESS REIMBURSEMENT PROGRAM FORM
For employees/retirees and dependents that participate in the University System of New Hampshire (USNH) medical
plan administered by Cigna.
UNIVERSITY SYSTEM OF NEW HAMPSHIRE