2024 Annual Physical Incentive Form

2024 Annual Physical Incentive Form I certify that I, ______________________________________________________ (print name), completed my annual physical, and I am receiving an incentive in the amount of $300. This incentive is for having a physical completed while actively being on First Internet Bank's medical plan in 2024. Physician Name: _________________________________________ Date completed: _________________________________________ _________________________________________________ _____________________________ Employee Signature Date Please return to HR department / payroll by December 18, 2024 [email protected] Fax: 000-000-0000