Name Annamalai Viswanathan Employee ID 3804 Date 9/27/2019 Wellness reimbursement program Paylocity’s fitness reimbursement program offsets the fees you pay for your gym memberships, Pilates and yoga classes, Weight Watchers Program & other weight loss programs – up to $200* each calendar year! What is eligible for reimbursement? Gym and health club memberships Yoga, pilates, and aerobics classes (when taught by a certified instructor) Weight Watchers monthly passes (meetings)† off site or Weight Watchers Online† Registration costs for Jenny Craig® Membership fees for TOPS®: Take Off Pounds Sensibly What can’t be reimbursed? Reimbursement is not available for social clubs, equipment, transportation, association memberships, lodging, meals, fitness clothing and vitamins. If you are enrolling in a weight management program that requires you to purchase food, the food will not be eligible for reimbursement under this program. Who is eligible for reimbursement? Regular full time and part time associates. How do I get reimbursed? Please submit the following to Zendesk under HR/Benefits: Documentation from the facility, program or event showing dates of contract and member(s) enrolled. Gym printout or signed notice showing 100 visits. Dated, original receipts from facility, program or event, or copies of bank/credit statements (if paid by electronic funds transfer) showing: 1. Member’s name 2. Name of activity Note: receipts will not be returned to the submitting party Please accumulate all your eligible receipts and make one request per calendar year. Be sure to submit for the reimbursement by 1/31 following the calendar year in which services were rendered/visits occurred. expenses during the year, please be sure to keep all of your receipts in order to submit one claim form per year. Timing: Processing of the reimbursement may take up to one (1) month. Date: Employee Name: Employee Location: Health Center/Weight Management Program: Amount of Reimbursement (Up to $200 Max): Reimbursement Amount $ 200.00 By submitting this form for reimbursement, I certify that I am eligible to receive this reimbursement. expenses during the year, please be sure to keep all of your receipts in order to submit one claim form per year. Timing: Processing of the reimbursement may take up to one (1) month. Date: Employee Name: Employee Location: Health Center/Weight Management Program: Amount of Reimbursement (Up to $200 Max): *Wellness reimbursements are considered a fringe benefit and are calculated as taxable wages.

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