Staples gym membership reimbursement form 2026

1. Click ‘Get Form’ to open the staples gym membership reimbursement form in the editor.
2. Begin by filling out the MEMBER INFORMATION section. Clearly print your CIGNA ID number, last name, first name, middle initial, and address including city, state, and zip code.
3. Indicate your gender by checking the appropriate box and specify your relationship to the claimant by selecting Subscriber, Spouse, or Dependent Child.
4. In the INFORMATION REQUIRED section, provide details about your health club or fitness program. Include the name of the facility and the date your membership or program began.
5. Enter the total amount you are submitting for reimbursement in the designated field. Ensure that you attach itemized photocopies of receipts and any relevant contracts.
6. Complete the CERTIFICATION AND AUTHORIZATION section by signing and dating the form to confirm that all information is accurate.
7. Finally, mail your completed form along with all required documents to CIGNA Healthcare at the address provided on the form.

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