Participant Tobacco Affidavit
First Name
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Last Name
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Participant Electronic Signature (Enter Full Name)/English
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- I do not use tobacco or nicotine products and have not for at least 6 months.
-By clicking the box, I confirm that all of the information provided is correct and truthful. -I attest that I have gotten a [action title] and understand that I will earn a reward for submission. Employees who have identified that they, and/or their spouse, enrolled in a Pioneer Medical Plan, are Tobacco User(s) and therefore required to pay a monthly Tobacco Surcharge of $50 per Tobacco User ($23.08 per pay period). If there is a change to your tobacco status from what we have on file, please complete the Tobacco Cessation Affidavit. You and your spouse must each complete your own on your own portal. Only complete this form if you incorrectly completed your tobacco election form or if you have recently become tobacco free. Tobacco user: If you have used tobacco products (cigarettes, cigars, pipe tobacco, chewing tobacco, etc.) in the last six months, you are considered a tobacco user. Nicotine replacement therapy includes patches, lozenges, gum or other products used to quit a tobacco habit and may contain nicotine. Please check the box below to indicate your updated tobacco status. I hereby attest that: I do not use tobacco or nicotine products and have not in at least 6 months. (Check box if true statement) Electronic Submission: Under penalties of perjury, I certify that I am the person accessing this web page and submitting the Tobacco Affidavit form. By checking the box and entering my name, I certify that all information on this form is true and correct. I also agree that the checkbox and my name typed below are to be used as my electronic signature.
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