Non-Nicotine User Affidavit As part of the Champion Wellness Program, employees are encouraged to learn about the health risks associated with Nicotine use and to take steps to quit using Nicotine products. Employees can earn an incentive for being Nicotine-free or committing to take steps to become Nicotine-free. To qualify for the discounted medical coverage premium, eligible employees must: Certify you are nicotine-free by completing the Nicotine-free Affidavit below OR Complete the “Quit Smoking” goal available through Vitality Wellness Program All Eligible employees must complete this form no later than December 31st to receive the credit. If you are a current Nicotine user, you will have to complete the Nicotine cessation program through Vitality to earn the credit.. Employee name: _____________________________ Date of Birth: ____ / ____ / ____ Employee Non-Nicotine User Affidavit I certify as a participant on the Champion health insurance plan that I do not presently smoke or use nicotine products, and (I) have not smoked or used Nicotine or nicotine products during the 6 months immediately preceding this affidavit. I understand that falsification of information is a violation of Company policy and that providing false information may subject me to repay the discount I receive. “Smoke or use of nicotine products” for purposes of this affidavit means any use of cigarettes, pipes, cigars, chew, dip, snuff, Vapes, E-cigarettes or any other Nicotine products regardless of the number of times, frequency, or method of use. I, the undersigned, have read the above and understand the penalties that may apply if the information in my statements is false. _____________________________________________________ Signature/Date Please check the appropriate box: I am a non-nicotine user. I have used Nicotine products in the past six months but will complete the “Quit Smoking” goal through the Vitality Wellness Program. I have no intention to quit Nicotine products and understand the credit is not available.
Print Name: __________________________________ Please return this form to HR.