*** Non Submission of this Non-Tobacco User Affidavit automatically reverts to your declining eligibility of Healthy Lifestyle Discount ***
I certify that I and my covered dependent(s) on Prowers Medical Center’s health insurance plan meet all of the qualifications for the Healthy Lifestyle Discount because we, (i) do not presently smoke or use tobacco products, and/or (ii) have not smoked or used tobacco products during the 6 months immediately preceding this affidavit. I understand that falsification of information is a violation of Company policy, which is subject to disciplinary action up to and including termination of employment. “Smoke or use of tobacco products” for purposes of this affidavit means any use of cigarettes, pipes, cigars or any other tobacco 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.
Electronic Signature (Type Name) (required)
Date Signed (required)
Please choose the appropriate statement from the dropdown:
I or my covered dependent(s) have quit using tobacco and have been tobacco-free for at least six monthsNeither I nor my covered dependent(s) have ever used tobaccoI and my covered dependent(s) decline the Healthy Lifestyle Discount
Employee Number (required)