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2023 WCIF Wellness Grant Request for Reimbursement

INSTRUCTIONS

Complete the following form to request reimbursement for WCIF Wellness Grant funding.

1. Upload copies of all necessary supporting documentation as defined in the 2023 WCIF Wellness Grant Regulations* (i.e. receipts, lists of incentive recipient names and prizes awarded).

2. Number all supporting documents according to their explanation of expense (refer to the item number above each form line).

Requests submitted without the above documentation may be returned and/or declined. All requests must be submitted by November 30, 2023. Any requests submitted after this date will not be accepted. 

Wellness Grant Request for Reimbursement Form

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                      I confirm that all expenses listed above are in compliance with WCIF 2023 Wellness Grant Regulations*. I understand that any noncompliant expenditures incurred will not be paid by WCIF and are therefore my or my employer's responsibility.
                      Date(Required)
                      *Acknowledgement of the 2023 WCIF Wellness Grant Regulations was a mandatory component of all initial 2023 grant applications. A copy of these regulations is available online here.