A-B Reimbursement Program for Weight Watchers® Offerings  
 
PLEASE PRINT 
(ALL questions must be completed by the employee) 

1) Name of Weight Watchers (WW) participant: ______________________________________________ 
 
2) Name of Employee:    ________________________________________________________________ 
 
3) Employee SAP ID#: ____________________    4) Amount of WW reimbursement:  $_______________ 
 
5) This reimbursement request is for WW participation FROM ________________ TO ________________ 
                                                                                                                                   (MM/DD/YY)                             (MM/DD/YY) 
6) This reimbursement is for how many weeks? _____________ 
 
7) CHECK THE WEIGHT WATCHERS OFFERING YOU ARE REQUESTING REIMBURSEMENT. 
Only one offering may be reimbursed for the same time period – no overlapping offerings.): 

 [    ] Unlimited Workshop + Digital  [    ] Digital Only   [    ] Other (explain) _______________
 
8) Have you reached Maintenance status, as defined by WW?  YES    NO    If “yes”, when? _______________ 
                                                                                                                                                                          (MM/DD/YY) 
9) Have your reached Lifetime Member status, as defined by WW?   YES    NO     If “yes”, when? _________________ 
                                                                                                                                                                                      (MM/DD/YY) 

This section must be signed by: 
	• For Studio WW Workshops: Weight Watchers Leader 
	• For Digital subscriptions, one of the following who can document your weight loss: PCP, 
	  Nurse, Dietician, Personal trainer, Life-Style coach, Fitness Instructor, or Wellness Coordinator. 

The above named person participated in the WW offering and lost 10% of total body weight or reached goal weight (if less than 10%) or completed the maintenance phase.

______________________________________                      ______________________________________
 
                        Signature                                                                                            Date	
Anheuser-Busch Companies encourages our employees, their spouses, and dependent children to participate in activities leading to healthier lives.  Your signature on this form affirms that this individual participated in the Weight Watchers offering and lost the weight as stated. 

Notes to the Participant: 

1.	Attach proof of payment. Some examples include cancelled checks, WW receipts, credit card statements (minus details of other charges), or E-confirmation date and amount paid.
2.	Submit this form and proof of payment to the employee’s local Wellness Coordinator. 
3.	Eligibility for reimbursement will be validated. Please obtain a copy of the “Frequently Asked Questions” (FAQ's) from your Wellness Coordinator or from the My HR Web Wellness Home Page for reimbursement eligibility. 
4.	If eligible, reimbursement will appear no later than the employee’s last paycheck of the following month after your Wellness Coordinator has submitted your request to the corporate office in St. Louis.