Professional Documents
Culture Documents
PLEASE PRINT ALL INFORMATION CLEARLY SUBSCRIBER INFORMATION (Person in whose name coverage is held) CIGNA ID Number Subscribers Last Name Subscribers First Name Middle Initial
City
State
Zip Code
MEMBER INFORMATION
Member's Last Name First Name Middle Initial Date of Birth
3. 4.
5. 6. 7.
TOTAL CHARGES: $
All Fitness Benefit payments will be sent to the Employee's address on file. CERTIFICATION AND AUTHORIZATION (This form must be signed and dated below) I authorize the release of any information to CIGNA HealthCare, Inc. 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, during this plan year. Employee's/Member's Signature:
Please mail this form (including copies of paid receipts) to:
CIGNA Healthcare Scranton Service Center Attn: Jennifer Petrochko PO Box 3299 Scranton, PA 18505-0299 Note: The program is provided and funded by Staples, Inc. CIGNA HealthCare acts as administrator only.
Date: