Unicare fitness form reimbursement 2026

1. Click ‘Get Form’ to open the UniCare Fitness Club Reimbursement Form in the editor.
2. Begin by entering your name in the 'Name of Enrollee' field, ensuring you include your last name, first name, and middle initial.
3. Next, input your UniCare ID Number in the designated field to verify your membership.
4. Fill out your address in the 'Enrollee Address' section, making sure it is accurate for correspondence.
5. Provide the name and address of your fitness club along with a contact phone number.
6. Enter your date of birth to confirm eligibility for reimbursement.
7. If applicable, fill in the 'Name of Member' and their relationship to you as the enrollee.
8. Attach proof of membership by checking the appropriate box and including a copy of your fitness club membership agreement.
9. Indicate the amount paid for your membership in the corresponding field.
10. Select one option from the proof of payment section that best describes how you paid for your membership. Ensure all receipts are clear and legible.
11. Finally, sign and date the form at the bottom to certify that all information provided is accurate before submitting it to UniCare State Indemnity Plan.

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