Tobacco Free Affidavit [Company Name] is implementing a $35/month surcharge to health insurance premiums for employees and/or covered spouses using tobacco effective [insert date].
Tobacco User Definition “Tobacco” or “tobacco products” includes tobacco of any kind, including the use of smokeless tobacco, “spit” tobacco, electronic cigarettes, cigars, cigarettes, pipes, vaping or any other smoking material or device.
By signing this Tobacco Affidavit, I certify that: I am a non-tobacco user and will not use tobacco products of any kind. I understand that my employer may require certification of my non-tobacco user status in the future. I understand that any dishonest or false representation of my non-tobacco user status will result in the immediate application of the tobacco surcharge to my health insurance premiums. I understand that to avoid the tobacco surcharge, I must return a completed affidavit to Human Resources by [insert date]. I am a non-tobacco user and will not use tobacco products of any kind. I want to participate in a Tobacco Cessation program and understand that I must start
the program by [insert date] and complete the program by [insert date] The tobacco surcharge will be removed upon my completion in the Tobacco Cessation Program or by quitting tobacco products, whichever comes first. Please contact me to provide me with information about the Tobacco Cessation program. I am a tobacco user and do not wish to participate in the Tobacco Cessation program. I understand this means I will incur a tobacco surcharge on my health insurance premiums.
Insured Member’s First Name (Print) Last Name
Insured Member’s Signature
Date
Return send this completed form to the HR Team by [insert date]